Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve iron Dextran infusions. You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary. The Plan must follow Medicare rules. Medicare rules say that iron infusions are covered when specific criteria are met. 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 you have a diagnosis of iron deficiency and multiple symptoms, including weakness, fatigue, confusion, depression, and more. The records do not support that you meet the Medicare criteria for coverage of iron infusions. The services are therefore not reasonable or medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve iron Dextran infusions.
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 you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not medically necessary. Our physician reviewer found the enrollee underwent photoselective vaporization of the prostate (PVP) on March 19, 2021. The physical therapy note dated March 29, 2021 states he needs minimal assist with bed mobility, transfers, and ambulating 15 feet. The occupational therapy note dated March 27, 2021 states he needs modified independence with eating, set-up for grooming, and minimal to total assist for bathing. He does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require 15 hours per week of rehabilitative services and regular physician evaluation. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy.
You asked the Plan to pre-approve the requested services. You say that you cannot hear from your right ear. The Plan denied your request. The Plan says the treatment is unproven for sudden hearing loss.
The Plan must follow Medicare rules. Medicare rules say that hyperbaric oxygen therapy is only covered under certain medical indications.
We looked at the file and Medicare rules. In this case, the records do not show that the services are being requested for a covered indication. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), intraoral x-ray imaging (D0220, D0230), bitewing x-rays (D0274), panoramic x-ray (D0330) and teeth cleaning (D1110) provided by an out-of-network (OON) provider on October 31, 2020.
You asked the Plan to pay for the dental services. You say that you were told this provider was in network. The Plan denied your request. The Plan says this provider is not in the Plan's network, and out-of-network services are not covered. The Plan has reviewed their internal records and have found no indication that this provider was recommended or that their network status was verified prior to services.
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 comprehensive oral evaluation (D0150), intraoral x-ray imaging (D0220, D0230), bitewing x-rays (D0274), panoramic x-ray (D0330) and teeth cleaning (D1110) provided by an out-of-network (OON) provider on October 31, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Norco 10-325mg 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 this medication is not a covered benefit under the enrollee's contractual policy.
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. Therefore, we decided that the Plan does not have to pre-approve the Norco 10-325mg 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gum surgery (D4266).
You asked the Plan to pre-approve the gum surgery. You say that you have a bad infection in the tooth and
your dentist advised you that this could spread. You are worried for your health and cannot afford the cost. The
Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's supplemental
dental benefit.
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 gum
surgery (D4266).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure provided on November 12, 2020. You asked the Plan to pay for the preventive procedure. You say that this service was for a follow up, and not for preventive reasons. The Plan denied your request. The Plan says this service is not covered by the Plan. 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 preventive procedure provided on November 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a replacement group 3 power wheelchair with accessories, including seat elevator and push handles (E2300, K0108).
You asked the Plan to preapprove the power wheelchair and accessories. You say that the enrollee needs a replacement wheelchair because they require the additional features. The Plan denied your request. The Plan says the enrollee already has a group 3 power wheelchair. The Plan also says that the (E2300) Seat Elevator does not serve a primary medical purpose and is statutorily non-covered. K0108 Push Handles do not serve a medical purpose.
The Plan must follow Medicare rules. The rules say that a replacement due to wear is not covered during the reasonable useful lifetime of the equipment (less than 5 years). The enrollee has a K0861 Group three power wheelchair and has obtained in within the five year rule. The additional requested features (the seat elevator E2300 and push handles K0108) are not considered to serve a medical purpose and would not be covered . Therefore, we decided that the Plan does not have to preapprove a replacement group 3 power wheelchair with accessories, including seat elevator and push handles (E2300, K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 4, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan
did not receive a prior authorization from the PCP or this provider.
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
physician's services. 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 physician's services provided on November 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued continuous positive airway pressure (CPAP)
device use.
You asked the Plan to pre-approve these services. You say that you have difficulty sleeping. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that continued CPAP use is covered when specific
criteria are met.
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
you do not meet the criteria for coverage. Our physician reviewer found the records show that you have
obstructive sleep apnea (OSA) but have been unable to meet the Medicare minimum use criteria for the CPAP
device. You have not been using the CPAP for at least four hours per night for at least 70 percent of the nights.
The records indicate you were having problems tolerating the CPAP but the records do not include plans to
address the tolerance issues. The continued CPAP use is therefore not reasonable or medically necessary at this
time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued continuous positive airway pressure (CPAP) device use.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a second opinion with an out-of-network (OON) provider. You asked the Plan to pre-approve the second opinion with an OON provider. You say that the type of cancer you have is rare. You say that you would like to go outside of the Plan's network for a second opinion. The Plan denied your request. The Plan says that a second opinion can be provided in-network, and that OON care is not medically necessary. Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 second opinion with an OON provider. Our reviewer says that the criteria for coverage of OON care have been met. Our physician reviewer found the Plan's denial is of not medically justified in that it is not offering adequate care to meet the enrollee's medical needs through referral to an in-network oncologist. Spindle Cell cancer of the breast is a rare entity and a multidisciplinary approach at an experienced center that would involve surgical, radiation, and medical oncologists is preferred. The enrollee's condition is unique, which makes it medically necessary for her to see the requested OON provider. There is a question of metastatic disease and a rare tumor, without clear guidelines to determine treatment. The Plan has not shown that their in-network providers have the expertise in Spindle Cell breast cancer or sarcoma in general. 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 second opinion with an OON provider have been met. Therefore, we decided that the Plan has to pre-approve a second opinion with the out-of-network (OON) provider. 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 cardiovascular panel provided on May 22, 2020.
You asked the Plan to pay for the cardiovascular panel. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says screening services with no relation to a medical diagnosis of disease for the health of the member are not a benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, the cardiovascular panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Additionally, the documentation submitted does not
include medical records to verify if Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular panel provided on May 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral evaluation (D0140), intraoral x-rays (D0220), pulp
vitality tests (D0460), and endodontic therapy (D3330) provided on September 30, 2019.
You asked the Plan to pay for the dental services. You say that you just paid the bill at the time and didn't think
anything of it. You state that you did not know you only had one year to file a claim. The Plan denied your
request. The Plan says this claim was not submitted in a timely manner. Claims need to be submitted within
one year of the date of service, as outlined in your contract.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the dental services was not filed until November 3, 2020. This means that
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we
decided that the Plan does not have to pay for the oral evaluation (D0140), intraoral x-rays (D0220), pulp
vitality tests (D0460), and endodontic therapy (D3330) provided on September 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs continued physical and occupational therapy. The Plan denied your request. The Plan says the enrollee does not require an intensive therapy program with multiple visits from a rehab doctor.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee was admitted to the acute hospital for mitral valve surgery and had respiratory failure requiring tracheostomy. She is now in a LTACH facility where she has been weaned from ventilator and tracheostomy has been decannulated. Her medical problems are stable. There are no complex nursing needs. She does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit and coinsurance for an
injection provided by a participating provider on June 19, 2019, to May 13, 2020.
You asked the Plan to waive the copayment for an office visit and coinsurance for an injection. You say that
you do not agree with these cost sharing amounts. The Plan denied your request. The Plan says the correct
copayment and 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 $45
copayment and a 20% coinsurance for practitioner/physician services/specialist and Medicare Part B
prescription drugs.
You have been asked to pay a $45 copayment for an office visit and a 20% coinsurance of the allowed amount
for an injection. The total allowed amount is $56.52. The total amount you are being asked to pay for the
injections is $11.31 ($56.52 x 20% = $11.31). The total amount you are being asked to pay is $101.31 ($45 +
$45 + $11.31 = $101.31). An office visit falls within the practitioner/physician services/specialist benefit
category and an injection falls within the Medicare Part B prescription drugs 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 an office visit and coinsurance for an injection provided by a
participating provider on June 19, 2019, to May 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of the torus mandibularis (D7473).

You asked the Plan to pre-approve the dental service. You say that the service should be covered. The Plan denied your request. The Plan says removal of the torus mandibularis is not listed as a covered service. The Plan also says that any services not listed 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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the removal of the torus mandibularis (D7473).