Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard, soft appliance (D9945).
You asked the Plan to pre-approve the dental item. You say that you need this for medical reasons. The Plan denied your request. The Plan says occlusal guard, soft appliance, is not listed as 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 occlusal guard, soft appliance, is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an occlusal guard, soft appliance (D9945).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

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. The rules say that Prolia 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 the services are not medically necessary. Our physician reviewer found the enrollee has documented osteoporosis. She has a history of frequent falls and received extensive physical therapy. Although she takes a Vitamin D supplement, she is not receiving adequate supplementation with calcium. There is no documented medical reason that the enrollee cannot safely take a daily calcium supplement. The review has determined that the enrollee does not meet all of the criteria for coverage in LCA A52399 for Prolia. It is not reasonable or medically necessary for the enrollee to receive Prolia.

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 Prolia.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an out-of-network referral for magnetic resonance imaging (MRI) of the pelvis.  You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are in-network diagnostic facilities available.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case 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 out-of-network referral for magnetic resonance imaging (MRI) of the pelvis.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on August 4, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on  August 4, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an endoscopy provided on September 22, 2021.

You asked the Plan to waive the copayment for the endoscopy. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.

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 $300 copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.

You have been asked to pay a $300 copayment for an endoscopy. Endoscopies fall within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 endoscopy provided on September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a home visit provided to the enrollee on  August 30, 2021.  You asked the Plan to pre-approve the visit. You say that palliative care should not have a copayment. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $25 copayment for a specialist office visits.   The enrollee has been asked to pay a $25 copayment for the visit. The visit falls within the a specialist office visits benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to pre-approve a home visit provided to the enrollee on August 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a positron emission tomography (PET)
scan of the heart provided on September 22, 2020.
You asked the Plan to waive the copayment for the PET scan. You say that you cannot afford to pay the bill.
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 $195
copayment for diagnostic and nuclear medicine radiological services, including PET scans.
You have been asked to pay a $195 copayment for the PET scan. The PET scan falls within the Outpatient
Diagnostic Tests and Therapeutic Services and Supplies 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 positron emission tomography (PET) scan of the heart provided on September 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) and prophylaxis - adult (D1110) provided August 3, 2021.

You asked the Plan to pay for the comprehensive oral exam and dental cleaning. You say that you were unaware that the dentist had opted out of Medicare. The Plan denied your request. The Plan says dental services are not covered when rendered by a provider who has opted out of Medicare.

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 comprehensive oral exam and dental cleaning when you see any licensed dental provider who accepts Medicare patients in the United States and has not opted out of Original Medicare. 

We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, we decided that the Plan's rules for coverage of the comprehensive oral exam and dental cleaning have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) and prophylaxis - adult (D1110) provided August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for sedation services (99156) provided January 17, 2021.
You asked the Plan to pay for the sedation services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the code billed shares a bundled relationship with another code billed.
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, we have confirmed that code 99156
has a bundled relationship with code 23650. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for sedation services (99156) provided January 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visits (99213-25) provided on August 31, 2021, and September 28, 2021.  You asked the Plan to pay for the office visits (99213-25). You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We find that CPT code 99213-25 is not supported in the medical record. The office visits at issue were billed with modifier 25, which is used to report a significant, separately identifiable Evaluation and Management (EM) service by the same physician or other qualified health care professional on the same day of a procedure or other service. There is no documentation of any significant, separately identifiable evaluation unrelated to the treatment provided to the enrollee on these dates of service. Therefore, we decided that the Plan does not have to pay for the office visits (99213-25) provided on August 31, 2021, and September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve office visits to be provided by out-of-network (OON) providers.  You asked the Plan to pre-approve the office visits. You say that you switched insurance plans and want to continue to see your providers. The Plan denied your request. The Plan says the providers are out-of-network.  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 office visits to be provided by out-of-network (OON) providers.  Your complaints about the insurance system is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.

You asked the Plan to pre-approve the Vertiflex Superion Spacer. You say that you would like reconsideration because the requested device is medically necessary. The Plan denied your request. The Plan says this Vertiflex device is experimental.

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 Vertiflex Superion Spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental and more research is needed to show its 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 Vertiflex Superion Spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve HH PT visits (CPT code G0151 x12), for the enrollee.  You asked the Plan to pre-approve the visits. You say that the services are necessary. The Plan denied your request. The Plan says the enrollee has had one hundred seventeen (117) physical therapy visits previously approved. The Plan states records show the Plan that the enrollee can walk two hundred fifty (250) feet with a rolling walker on level surfaces and one hundred sixty (160) feet on uneven surfaces. The Plan states the enrollee requires little to no help with moving in bed and the enrollee has caregivers available who can help the enrollee with many of their daily living tasks. The Plan states the enrollee should be able to continue therapy at a lower level of care and this can be in the outpatient setting or with the enrollee's home exercise plan. The Plan states the enrollee's records do not support the need for a skilled physical therapist to make more home visits at this time.  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 the visits. Our physician reviewer found the health plan's denial should be upheld. The enrollee does not have documented, ongoing HH PT needs. The enrollee appears to be functioning at a level commiserate with a lower level of care. As such, the requested, ongoing, HH PT services are not medically necessary or reasonable.  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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve HH PT visits (CPT code G0151 x12), for the enrollee.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pre-approve a continuation of skilled nursing facility (SNF) care.  You asked the Plan to pre-approve a continuation of SNF care. You say that the enrollee has two very large surgical wounds that are infected and not healing. You say that the enrollee would not receive the wound care needed at home and would probably be back in the hospital within a week. The Plan denied your request. The Plan says that the criteria for coverage of SNF care have 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 a continuation of SNF care. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee has documented skilled nursing needs, in the need of daily wound care to large, infected wounds on her back.  The enrollee does not have documented skilled therapy needs.  Daily skilled services are required to establish a maintenance program or to prevent deterioration of the enrollee's condition.  The enrollee's care needs, as a practical matter, cannot be provided at a lower level 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 a continuation of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve a continuation of skilled nursing facility (SNF) care.       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: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve Lutathera.  You asked the Plan to pre-approve Lutathera. You say that you would like reconsideration because the requested drug is medically necessary. The Plan denied your request. The Plan says that there is no support in the compendia utilized by Medicare or in Medicare approved literature for the use of more than four total doses of Lutathera.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.   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 Lutathera. Our reviewer says that the documentation supports that the requested drug is safe and effective and otherwise medically necessary for the treatment of the member's condition. Our physician reviewer found further treatments with Lutathera can be administered if patients experience progression after a reasonable period of disease response or stability (typically defined as greater than 12 months). Repeat treatments often consist of two cycles each, and limited data indicate a median time to progression of approximately 17 months.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Lutathera have been met. Therefore, we decided that the Plan has to pre-approve Lutathera.   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: 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 an LTACH is a safer option for you. The
Plan denied your request. The Plan says you are receiving appropriate care.
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 the records show that you are receiving appropriate care at the present acute care
hospital. You do not require services at the LTACH that are not available at the acute care hospital where you
are currently receiving care. There are no services available at the LTACH that you require 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Factor V Leiden (F5) and F2 genetic testing.
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 covered.
The Plan must follow Medicare rules. Medicare rules say that F5 and F2 testing is not medically necessary.
We looked at the file and Medicare rules. The testing at issue is F5 and F2 genetic testing. This testing is
denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pre-
approve Factor V Leiden (F5) and F2 genetic testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3000).

You asked the Plan to pre-approve foot orthotics. You say that the requested item is a medical necessity for you. 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 do not show that you suffer from diabetic foot disease or that you 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 (L3000).