Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occupational therapy (OT) evaluation, low complexity (97165).
You asked the Plan to pre-approve OT services. You say that the service is necessary. The Plan denied your
request. The Plan says the treating provider did not sign the certification of medical necessity.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of OT service have not been met. Specifically, the file indicates that the
certification of medical necessity was not signed by the treating provider. This is required as the doctor needs
to approve or modify the treatment plan by the occupational therapist. Therefore, we decided that the Plan does
not have to pre-approve an occupational therapy (OT) evaluation, low complexity (97165).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you have neuropathy, your balance is bad, and
you have fallen twice. 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 foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device.
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the
criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that pneumatic compression devices are only covered
under certain medical indications.
We looked at the file and Medicare rules. The records do not show that the enrollee has lymphedema extending
into the trunk. The records also do not include the trial and failure of treatment with a basic pump. Based on
this information, we decided that Medicare rules for coverage of the requested device have not been met.
Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer
found the enrollee has a history of osteoporosis. The documentation does not support that the enrollee has tried
and failed an oral bisphosphonate drug (e.g., alendronate, ibandronate, or risedronate) and (2) zoledronic acid
(generic Reclast). There is no documentation provided indicating the plan's required drugs would likely be less
effective and/or likely have adverse effects for the 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 Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a right below knee prosthesis to be provided by an out-
of-network (OON) provider.
You asked the Plan to pre-approve the prosthesis. You say that you are requesting prior authorization for a new
prosthesis for the enrollee. The Plan denied your request. The Plan says enrollee's must receive their medical
services from an in-network provider with the exception being urgent or emergent services. Non-emergent
services with non-contracted providers require prior authorization before services being rendered.
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 right below knee prosthesis 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 power seat elevation system (E2300) for a power
wheelchair.
You asked the Plan to pre-approve a power seat elevation system. You say that the requested item is a medical
necessity for the enrollee. The Plan denied your request. The Plan says the requested item is not a covered
benefit.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature and power
standing feature are non-covered because they are not primarily medical in nature. Based on this information,
we decided that Medicare rules for coverage of a power seat elevation system have not been met. Therefore, we
decided that the Plan does not have to pre-approve a power seat elevation system (E2300) for a power
wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an alert or alarm device, not otherwise classified
(A9280).
You asked the Plan to pre-approve an alert or alarm device. You say that this should not have been denied
because you are 77 years old and lives alone. You want to remain independent, but you have fallen in the past.
The Plan denied your request. The Plan says this item is not a covered benefit.
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-approve an alert or alarm device, not otherwise classified (A9280).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for psychotherapy services provided from January 19, 2021, to September 28, 2021.
You asked the Plan to waive the copayments for the psychotherapy services. You say that you feel that the copayment amount is too high. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each specialist visit. You have been asked to pay a $40 copayment for each specialist visit for the psychotherapy services. The file shows that you had a total of 4 visits from January 19, 2021, to September 28, 2021, for a total of $160 ($40
copayment x 4 visits = $160). The psychotherapy services fall within the Physician/Practitioner Services, Including Doctor's Office Visits 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 copayments for psychotherapy services provided from January 19, 2021, to September 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upper and lower dentures.
You asked the Plan to pre-approve the dentures. You say that you are only able to eat soft foods which is not
providing you enough nutrition. You also say that your current dentures are outdated. The Plan denied your
request. The Plan says you had dentures made less than 5 years 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, you are limited to one upper and/or
lower denture every five years. The record shows that you received a complete maxillary denture (D5110) on
July 12, 2019 and a complete mandibular denture on November 13, 2019 and your complete upper and lower
denture benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-approve upper
and lower dentures.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 7, 8, 9, and 10.
You asked the Plan to pre-approve the crowns. You say that you were told to appeal the Plan's decision. The
Plan denied your request. The Plan says this service is not covered under your 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
crowns (D2750) for tooth #'s 7, 8, 9, and 10.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing (86803) provided on August 5, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for laboratory testing. You say that the services were medically reasonable and necessary as ordered by the patient's treating nephrologist. You also say that you have an exclusive agreement with the dialysis facility where the patient received treatment. The Plan denied your request. The Plan says the rendering provider is a non-participating provider, and the referring provider is a non-participating provider with the Plan. The Plan also says they did not authorize any services for this facility 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 had network providers available who could have provided 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 laboratory testing (86803) provided on August 5, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. 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 foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea.
You asked the Plan to pre-approve Eylea. The Plan denied your request. The Plan says the enrollee has not tried and failed the ophthalmic formulation of bevacizumab.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Eylea. Our physician reviewer found that the enrollee has a diagnosis of Tributary (branch) retinal vein occlusion, left eye, with macular edema. The Plan requires a trial of Bevacizumab before they will approve the requested drug. The case file does not contain documentation of trial and failure of Bevacizumab. It is not documented that Bevacizumab would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to pre-approve Eylea.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office consultation and follow-up care to be rendered
by the out-of-network (OON) provider.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the
Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render
the requested services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office
consultation and follow-up care to be rendered by the out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).
You asked the Plan to pre-approve the insertion of stabilization device (22869). You say that the member has
suffered from this condition for approximately six years and has failed more than six years of conservative
approaches to treatment. You say that this treatment is considered safe and effective, and the authorization
should be approved. The Plan denied your request. The Plan says this procedure is still being investigated as
there is limited evidence available to show the effectiveness and safety of this procedure.
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 insertion of stabilization device
(22869). Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found that interspinous process distraction devices remain
experimental. More research is needed to show safety and efficacy.
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 insertion of stabilization device (22869) have not been met. Therefore, we
decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided May 9, 2021.
You asked the Plan to waive the copayment for the non-emergency ambulance service and ground mileage. You say that you cannot afford the cost. The Plan denied your request. The Plan says the copayment was applied correctly.
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 $230 copayment for each one-way Medicare-covered ground ambulance trip. You have been asked to pay a $230 copayment for the non-emergency ambulance service and ground mileage. The non-emergency ambulance service and ground mileage falls within the Ambulance 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 for ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided May 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound debridement services provided on September 29, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the wound debridement services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the wound debridement services provided on September 29, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for limited oral evaluation - problem
focused (D0140), endodontic therapy, molar tooth (excluding final restoration) (D3330) and intraoral -
periapical first radiographic image (D0220) provided July 12, 2021.
You asked the Plan to provide additional payment for the limited oral exam, root canal and periapical x-ray.
You say that you would like these services covered. The Plan denied your request. The Plan says an exception
was granted to cover the requested services up to your maximum dental 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. The Plan covers the limited
oral exam, root canal and periapical x-ray up to a $1,500 allowance amount.
We looked at the file and Medicare rules. The Plan provided documentation showing that you had $838
remaining in your annual allowance amount at the time the requested claims were processed. This amount was
applied towards your dental services. Therefore, we decided that the Plan does not have to provide additional
payment for limited oral evaluation - problem focused (D0140), endodontic therapy, molar tooth (excluding
final restoration) (D3330) and intraoral - periapical first radiographic image (D0220) provided July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a denosumab injection provided on
August 26, 2021.
You asked the Plan to waive the coinsurance for the injection. You say that you did not know there was such a
dramatic copayment. The Plan denied your request. The Plan says the correct coinsurance was 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 Part B non-chemotherapy drugs, including osteoporosis drugs.
You have been asked to pay $251.64, which is 20% of the allowed amount for the injection ($1258.20 allowed
amount x 20% coinsurance = $251.64). The 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 coinsurance for a denosumab injection provided
on August 26, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on
September 14, 2021.
You asked the Plan to waive the copayment for the colonoscopy. You say that you were informed that the
procedure was preventive and would have no copayment. The Plan denied your request. The Plan says you
have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0
copayment for a screening colonoscopy. A screening can become diagnostic in the same visit.
Your contract with the Plan also clearly says that you must pay a $175 copayment for each outpatient hospital
visit.
You have been asked to pay a $175 copayment for the colonoscopy. The record shows that you had the
procedure done due to iron deficiency anemia, which makes the procedure diagnostic in nature according to
your Plan benefits. The colonoscopy falls within the Colorectal Cancer Screening 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 a diagnostic colonoscopy provided on September 14, 2021.