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

We decided that the Plan does not have to pre-approve expandable controller, harness and connection for a 
power wheelchair (E2377, E2313, E2311). 
 
You asked the Plan to pre-approve the wheelchair components. You say that the wheelchair components are 
necessary. The Plan denied your request. The Plan says they will overturn the request for a group 3 power 
wheelchair, but you do not meet coverage criteria for the additional wheelchair components. 
 
The Plan must follow Medicare rules. Medicare rules say that he expanded controller components (E2377, 
E2313, E2311) are requested to control power options through the expandable controller. Because the enrollee 
has adequate upper extremity strength and is independent with UE ADLs, the enrollee is able to the control the 
three power options with their own switches, there is no need to control the power option through an 
expandable controller. This upper extremity function is adequate to control the power options using their own 
switch which are included in the allowance of these power options. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the wheelchair components have not been met. Therefore, we decided that the Plan does not have 
to pre-approve expandable controller, harness and connection for a power wheelchair (E2377, E2313, E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206), the panoramic x-ray (D0330), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) provided on November 2, 2020.

You asked the Plan to pay for the fluoride varnish, panoramic x-ray and periapical x-rays. You say that the provider in this case is listed in the Provider Directory. You say that a plan representative advised the provider was in network. You also say that the doctor's office advised the provider was in network too. The Plan denied your request. The Plan says that fluoride varnish is not listed as a covered service. The Plan says that panoramic x-ray is not listed as a covered service. The Plan also says that periapical x-rays are not listed as covered services either.

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 fluoride varnish, panoramic x-ray, and periapical x-rays are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206), the panoramic x-ray (D0330), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) provided on November 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the transcutaneous electrical nerve stimulation (TENS) 
machine and leads. 
 
You asked the Plan to pre-approve the TENS unit. You say that you require the TENS device. The Plan denied 
your request. The Plan says a TENS device is not covered for CLBP if you are not enrolled in a clinical study. 
 
The Plan must follow Medicare rules. Medicare rules say that a TENS unit is not covered unless there is a 
condition of CLBP for longer than three months and the enrollee is part of a clinical study. The Enrollee is not 
in a clinical study.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the TENS unit have not been met. Therefore, we decided that the Plan does not have to pre-
approve the transcutaneous electrical nerve stimulation (TENS) machine and leads.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the pulmonary rehabilitation service, therapeutic procedure to improve respiratory function (G0239) provided February 4,2020.

You asked the Plan to waive the copayment for the pulmonary services. You say that you do not agree with the copay of $33.43 on the claims processed for pulmonary rehab services for the 2020 year and is confused why you are paying more than what the EOC shows for a copay on pulmonary rehab services. The Plan denied your request. The Plan says that the claim was processed with the correct copayment applied per the Evidence of Coverage for Outpatient hospital services.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay $20 copayment per visit for pulmonary rehabilitation services. 

The Plan says you must pay $33.43, the allowed amount for $225 copayment for outpatient hospital services. Based on the Plan contract, however, you cannot be asked to pay more than $20 copayment per visit for pulmonary rehabilitation services. Therefore, we decided that the Plan has to waive the copayment for the pulmonary rehabilitation service, therapeutic procedure to improve respiratory function (G0239) provided February 4,2020.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950) and periodontal maintenance (D4910).

You asked the Plan to pre-approve the core buildup and periodontal maintenance. The Plan denied your request. The Plan says these services are not covered under the enrollee's benefit 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 pre-approve a core buildup, including any pins when required (D2950) and periodontal maintenance (D4910).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator (E0466).

You asked the Plan to pre-approve the portable ventilator. You say that the portable ventilator is necessary. The Plan denied your request. The Plan says portable ventilator is not supported in the medical record.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 portable ventilator. Our reviewer says that the service is not medically necessary. Our physician reviewer found the record does not indicate that other modalities have been tried or why based upon the specifics of the enrollee's medical condition, other modalities would not be appropriate. The record does not provide detailed information in the medical record to justify the treatment selected. The elements of the coverage criteria are not satisfied. The enrollee does not meet coverage criteria for the requested service.

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 portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an endodontic therapy (D3330).

You asked the Plan to pre-approve the endodontic therapy. The Plan denied your request. The Plan says this service is 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 an endodontic therapy (D3330).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve one office visit and treatment to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve one office visit and treatment to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.

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 one office visit and treatment to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the vision exam provided on April 14, 2021. 
 
You asked the Plan to waive the deductible for the vision exam. You say that you should not be responsible for 
the deductible because the doctor wanted to do your left eye exam again. The Plan denied your request. The 
Plan says you have been asked to pay the correct cost-sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $250 deductible which applies to each Medicare-covered outpatient 
visit for services to diagnose and/or treat a disease or condition of the eye. 

The vision exam you asked the Plan to waive the deductible for falls within the "Vision services" benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 
deductible which applies the vision exam. This cost sharing is a contractual obligation that had not been met at 
the time the vision exam was received on April 14, 2021. Therefore, we decided that the Plan does not have to 
waive the deductible for the vision exam provided on April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT).

You asked the Plan to pre-approve IGRT. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there are no peer-reviewed publications that demonstrate the use of daily IGRT in conjunction with three-dimensional conformal radiation therapy during the initial phase of photon results in lower complications for the enrollee's condition.

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 IGRT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a body-mass index below 23 and therefore is not obese, which could justify IGRT if set-up was challenging. There is no specific rationale offered for IGRT in this case. Routine use of IGRT is not within accepted standards of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vertebroplasty/kyphoplasty surgery. 
 
You asked the Plan to pre-approve vertebroplasty/kyphoplasty. You say that you are appealing this denial. The 
Plan denied your request. The Plan says the denial of authorization for this service is correct, because the 
enrollee has retropulsion of the bone into the spinal canal and compression on the spinal cord. 
 
The Plan follows Medicare rules. Medicare rules state that vertebroplasty/kyphoplasty may be covered by 
Medicare under certain clinical circumstances. 
 
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 vertebroplasty/kyphoplasty. Our 
reviewer says that the enrollee does not meet the Medicare criteria for this surgery. Our physician reviewer 
found the record indicates that the enrollee has had imaging demonstrating a T10 acute fracture with 
retropulsion into the canal. The record indicates that the enrollee has an old T12 compression fracture with 
almost complete loss of vertebral height and retropulsion. The imaging report does not indicate T11 fracture. 
Therefore, the requested service 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 vertebroplasty/kyphoplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve vertebroplasty/kyphoplasty surgery.
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 the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH 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 documentation provided necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at 
the LTACH that are not available at the present setting where he 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-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from August 18, 2021, forward.

You asked the Plan to pre-approve inpatient psychiatric care from August 18, 2021, forward.. You say that the services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue were not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 inpatient psychiatric care from August 18, 2021, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of August 18, 2021, forward. Our physician reviewer found the enrollee did not require inpatient mental health treatment beyond August 18, 2021, as she was not a danger to herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from August 18, 2021, forward. have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from August 18, 2021, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair power seat elevation system (E2300).

You asked the Plan to pre-approve the seat elevation feature. You say that the features should be covered. The Plan denied your request. The Plan says they will overturn the request for a group 3 power wheelchair, but not the seat elevation feature (E2300).

The Plan follows Medicare rules. Medicare rules say that power seat elevation feature (E2300) is non-covered because they are not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair power seat elevation system (E2300).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the breast biopsy provided on February 22, 2021.

You asked the Plan to waive the cost share for the breast biopsy. You say that you did not have a surgical procedure or a hospital service. You say this was a diagnostic radiology test which was categorized incorrectly. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible that applies towards the breast biopsy and a $350 copayment which applies to Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, including but not limited to hospital or other facility charges.

The breast biopsy you asked the Plan to waive the cost share for falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards the breast biopsy a $350 copayment which applies to the breast biopsy. The record shows you were charged code 19081 which is considered a surgical procedure.

This cost sharing is a contractual obligation that had not been met at the time the breast biopsy was received on February 22, 2021. Therefore, we decided that the Plan does not have to waive the cost share for the breast biopsy provided on February 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device. 
 
You asked the Plan to pre-approve the power mobility device. You say that you require the PMD to be able to 
get to your car or go to the grocery store. The Plan denied your request. The Plan says the request is for outside 
activities, therefore denied as it is supposed to be for in the home 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power mobility device. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the review indicates 
that the PMD is being requested for outside activities. Therefore, it is not covered and an evaluation is not 
necessary at this time. 

According to the NCD, it requires that the enrollee have a mobility limitation that significantly impairs his/her 
ability to participate in one or more MRADLs in the home. The enrollee does not have a personal mobility 
deficit that impairs participation in MRADLs. The enrollee's mobility deficit cannot be helped by the use of a 
walker, cane, or manual wheelchair. 
 
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 power mobility device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power mobility device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an OON
provider.

You asked the Plan to pre-approve office services. You say that you need this type of doctor. The Plan denied
your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-
network with the Plan and authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to 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
ophthalmology services to be provided by an OON provider.