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

We decided that the Plan does not have to pre-approve 6 additional non-emergency routine transport trips.
You asked the Plan to pre-approve 6 additional trips. You say that you need 6 additional trips to be approved. You say that your kids are not available to take you to the eye appointments that are necessary before you can have surgery. The Plan denied your request. The Plan says 10 one-way routine non-emergency transport trips to plan-approved locations are covered every year. The Plan also says that the frequency limit has been reached.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 10 one-way trips trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 6 additional non-emergency routine transport trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider.
You asked the Plan to pre-approve an office visit. You say that you were seen by another neurologist and was
not able to help you. The Plan denied your request. The Plan says the requested services can be provided by a
network 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 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
an office visit to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standard manual wheelchair (K0001).
You asked the Plan to pre-approve a standard manual wheelchair. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for a manual wheelchair have not been met.
The Plan must follow Medicare rules. Medicare rules say that a manual wheelchair for use inside the home is covered if the criteria listed in the Medicare rules section have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a standard manual wheelchair have not been met. Specifically, the provided records do not address whether the enrollee's mobility limitation can be sufficiently resolved by the use of an appropriately fitted cane or walker. Furthermore, the records indicate do not indicate that the enrollee's home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is requested, nor that the enrollee has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is requested in the home during a typical day. Therefore, we decided that the Plan does not have to pre-approve a standard manual wheelchair (K0001).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee surgery.
You asked the Plan to pre-approve knee surgery. You say that the services are necessary. The Plan denied your
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been
met.
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 knee surgery. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the
medical necessity of this request as an exception to guidelines. Therefore, the request for knee arthroscopy with
meniscectomy (medial or lateral, including any meniscal shaving) is 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 knee surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve knee surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve operating room services.
You asked the Plan to pre-approve operating room services. You say that you will have 3 wisdom teeth extracted and needs anesthesia to soften the pain. The Plan denied your request. The Plan says the service is not a covered 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 operating room services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiology services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve cardiology services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a network 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 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 cardiology services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on March 6, 2021.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation does not support that 22 or more drug classes were performed for this date of service to support the billing of code G0483. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on March 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).
You asked the Plan to pre-approve the complete maxillary denture and complete mandibular denture. You say that the enrollee's dentures do not fit, and he is having a hard time wearing them. You also say that the enrollee's existing dentures are not flexible and need to be remade. The Plan denied your request. The Plan says these services are limited to once every 60 months. The Plan also says that these services exceed the benefit allowance.
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 enrollee is limited to 1 complete or partial denture every 5 years. The record shows that the enrollee received a maxillary immediate denture and mandibular immediate denture on November 23, 2020 and the enrollee's denture benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve noncovered item, transit system (A9270)
You asked the Plan to pre-approve a transit system. You say that please reconsider covering the requested items since these are medically necessary in her order for her to use the approved wheelchair comfortably. The Plan denied your request. The Plan says durable medical equipment is only covered for use within the home.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a transit system have not been met. Therefore, we decided that the Plan does not have to pre-approve noncovered item, transit system (A9270)
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 IRF care is medically necessary for this enrollee. The
Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee does not
require an intensive rehabilitation program to return to baseline, does not have complex medical management
needs, and does not require supervision by a rehabilitation physician. The enrollee can be well served with
skilled therapy at home or at a nursing facility.
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 considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the
documentation does support a need for physical and/or occupational therapy, there is no documented need for
an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an
IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of each additional anterior segment aqueous drainage device (0376T).
You asked the Plan to pre-approve insertion of each additional anterior segment aqueous drainage device. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that CPT code 0376T for additional device insertions is not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of each additional anterior segment aqueous drainage device have not been met. Specifically, the request is for additional device insertions, which is a non-covered service. Therefore, we decided that the Plan does not have to pre-approve insertion of each additional anterior segment aqueous drainage device (0376T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee brace (L1851) for the enrollee.
You asked the Plan to pre-approve the brace. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not medically necessary.
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 brace. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the record indicates that the enrollee has not had a recent injury or surgery. The record does not indicate
the presence of knee instability. The elements of the coverage criteria were not satisfied.
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 brace have not been met. Therefore, we decided that the Plan does not have
to pre-approve a knee brace (L1851) for the enrollee
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 home health visits for skilled nursing care.

You asked the Plan to pre-approve skilled nursing home health visits. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for home health services have not been met.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve skilled nursing home health visits. Our reviewer says that the requested services are not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee does not have documented skilled nursing needs (for example, intravenous administrations, complex wound care, new/problematic ostomy). 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of skilled nursing home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 home health visits for skilled nursing care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that you would like to appeal this service. The Plan denied your request. The Plan says this request does not meet the Plan's coverage criteria and 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 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 there is no evidence that the enrollee requires services that are not currently available. As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. Our reviewer found that the enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider.
You asked the Plan to pre-approve an office visit. You say that you feel that the requested services are
medically necessary. The Plan denied your request. The Plan says the requested services can be provided by a
network 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 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
an office visit to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network ophthalmologist.

You asked the Plan to pre-approve these services. You say that you have been seeing this doctor for 15 years. The Plan denied your request. The Plan says the services are available from network providers.

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 an out-of-network ophthalmologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nine localized deliveries of antimicrobial agents (D4381 x9) and periodontal scalings and root planings (D4341) of the upper right, upper left, lower right, and lower left quadrants
You asked the Plan to pre-approve the localized deliveries of antimicrobial agents and scalings and planings. You say that you have a bleeding problem with your gums, the gum medicine is not covered, and you need a deep cleaning. The Plan denied your request. The Plan says localized delivery of antimicrobial agents is not covered under your benefit plan. The Plan also says that you received scalings and planings less than twenty-four months ago.
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, localized delivery of antimicrobial agents is not among those covered under this benefit. The contract also says that periodontic scaling and root
planing is only covered once every 24 months. The record shows that you received periodontal scalings and root planings (D4341) of the upper right and lower right quadrants on January 21, 2021, and periodontal scalings and root planings (D4341) of the upper left and lower left quadrants on January 27, 2021 and your periodontal scaling and root planing (D4341) benefit for each quadrant has been exhausted. Therefore, we decided that the Plan does not have to pre-approve nine localized deliveries of antimicrobial agents (D4381 x9) and periodontal scalings and root planings (D4341) of the upper right, upper left, lower right, and lower left quadrants.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be provided by an out-of-network
(OON) provider.
You asked the Plan to pre-approve the second opinion. You say that you think this provider might be able to
provide a better treatment plan for you. The Plan denied your request. The Plan says the requested services can
be provided by a network 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 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 second opinion to be provided by an out-of-network (OON) provider.