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

We decided that the Plan does not have the services a vision care office visit received on November 17, 2021.
You asked the Plan the services the services. You say that there was nothing medical in nature for this visit. The Plan denied your request. The Plan says the copayment was applied correctly in this case.
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 copayment for eye exams.
You have been asked to pay a $20 copayment for the services. The services fall within the eye exams 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 the services a vision care office visit received on November 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new power wheelchair (PWC).
You asked the Plan to pre-approve the new PWC. You say that the PWC you have is beyond repair and further repairs cannot be covered. You feel that the Plan must replace the PWC due to the medical necessity of the item. The Plan denied your request. The Plan says you were provided with a new PWC in 2019. There is no evidence in the record that this was lost or irreparably damaged by a single event.
The Plan must follow Medicare rules. Medicare rules say that durable medical equipment that has suffered irreparable wear from day-to-day use over time cannot be replaced within the 5-year RUL. We looked at the file and Medicare rules. We also requested and obtained documentation to confirm the receipt of a PWC in 2019. You have been provided a PWC that is within the RUL of 5 years. No evidence has been submitted to show that it was damaged beyond repair by a single event. While there may be wear that requires repair, or irreparable wear, replacement was correctly denied since the PWC is within the RUL. Though this PWC may be appropriate for you, Medicare does not cover replacement in this situation. Therefore, we decided that the Plan does not have to pre-approve a new power wheelchair (PWC).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an interspinous stabilization device.  You asked the Plan to pre-approve the requested services. You say that the enrollee is having a severe functional limitation due to the pain. The Plan denied your request. The Plan says the device is contraindicated 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 the requested services. Our physician reviewer found that interspinous stabilization devices remain experimental. More research is needed to show its efficacy. Therefore, the request 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous stabilization device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210) provided on October 14, 2021.
You asked the Plan to pay for the dental services. You say that you did not know about frequency limitations. You also say that a new dentist always requires x-rays and exams. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan says that 1 complete series x-ray is covered every 3 plan years. The Plan also says that the frequency limits have been exceeded.
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 and the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation and complete series x-ray that you received on April 13, 2019, less than 3 years ago. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210) provided on October 14, 2021.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pre-approve BRCA 1 and 2 testing and gene analysis.  

You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says that the records do not show that the criteria apply in this case.  

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.   

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 testing. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found you meet the criteria for this testing based on a personal history of breast cancer, twice, at any age. You also have a close relative with breast cancer, which meets the criteria.  

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 testing have been met. Therefore, we decided that the Plan has to pre-approve BRCA 1 and 2 testing and gene analysis.   

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: Unfavorable

We decided that the Plan does not have to pre-approve Epogen (J0885).
You asked the Plan to pre-approve Epogen. The Plan denied your request. The Plan says there is no record that shows the enrollee has tried one of the preferred drugs, Aranesp or Retacrit, and it has not worked or that the enrollee has medical reasons that prevents them from using one of them.
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 Epogen. Our reviewer says that Epogen (J0885) is not medically reasonable and necessary. Our physician reviewer found the record indicates that the enrollee has non-small cell lung cancer with metastatic lesions. The requested medication is a new start. Our reviewer found that the provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the Plan's preferred step one alternative. Our physician reviewer also found that the elements of the coverage criteria are not satisfied, and the requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Epogen have not been met. Therefore, we decided that the Plan does not have to pre-approve Epogen (J0885).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for prophylaxis (D1110), and a periodic oral evaluation (D0120) provided by an out-of-network provider on August 2, 2021.

You asked the Plan to pay for prophylaxis and a periodic oral evaluation. You say that you should not have to pay for this. The Plan denied your request. The Plan says services provided by an out-of-network provider are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit when provided by an out-of-network dentist.

Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110), and a periodic oral evaluation (D0120) provided by a participating provider on August 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2392) provided on October 26, 2021.

You asked the Plan to pay for the resin-based composite. You say that this procedure was medically necessary for your stem cell transplant, and you believe it should be covered. The Plan denied your request. The Plan says this procedure is not a benefit under your dental plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-based composite (D2392) provided on October 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) of the head (70554) provided on October 10, 2021.
You asked the Plan to pay for the MRA of the head. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT code 70553 and 70554.
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 70554 is a column II code to column I code 70553. 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 the magnetic resonance angiography (MRA) of the head (70554) provided on October 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the compounded drug rendered on August 18, 2020.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code J7999 is not supported.  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 J7999 is compounded drug, not otherwise classified.  We find that CPT code J7999 is not supported in the medical record. Specifically, the documentation does not support the units billed. 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 pay for the compounded drug rendered on August 18, 2020.
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 out-of-network (OON) provider.  You asked the Plan to pre-approve an office visit. You say that this is medically necessary. The Plan denied your request. The Plan says there are in-network providers available for the enrollee's medical needs.  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 out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral exam (D0140), panoramic x-ray (D0330) and extractions (D7140) provided on July 14, 2021.
You asked the Plan to pay for the dental services. You say that you were told by customer service that there were no in-network dentists, and you could see whichever provided you wanted. The Plan denied your request. The Plan says the provider in this case has opted out of Original Medicare. When you use a dental provider who has opted out of Medicare, you are not eligible for reimbursement under this 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. The Plan requires you to receive dental care from a provider who participates in Original Medicare in order to receive reimbursement.
Though the Plan offers a dental benefit in excess of Medicare coverage, the services in this case were performed by a provider who has chosen to opt out of Original Medicare. Therefore, we decided that the Plan does not have to pay for the limited oral exam (D0140), panoramic x-ray (D0330) and extractions (D7140) provided on July 14, 2021.
Your complaint about potential misinformation or a lack of information from a Plan representative 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve darbepoetin alfa, 1 microgram (non-ESRD use) injection (CPT code J0881), for the enrollee.  You asked the Plan to pre-approve the medication. You say that the medication is medically necessary for the enrollee. The Plan denied your request. The Plan says the Part B step therapy criteria states the enrollee must try and fail or have documentation of an adverse effect of Retacrit.  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 the medication. Our physician reviewer found the record indicates that the enrollee has chemotherapy induced anemia. The requested medication is a new start. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.  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 medication have not been met. Therefore, we decided that the Plan does not have to pre-approve darbepoetin alfa, 1 microgram (non-ESRD use) injection (CPT code J0881), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) and electronic connection (E2311).  You asked the Plan to pre-approve an expandable controller with harness and electronic connection. You say that that the requested items are a necessity for your care. The Plan denied your request. The Plan says medical necessity rules for the requested items 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 an expandable controller with harness and electronic connection. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found that you do not require non-proportional input devices (e.g., sip and puff, head array, etc.). You do not require a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. You have 3 power options of tilt, recline, and power elevating leg rests but you do not need to control the power options through a joystick. Your upper extremity strength and function support that you can control any power options through their own switches.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller with harness and electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) and electronic connection (E2311).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your records do not show that you require daily skilled services that can only be provided on an inpatient basis.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a group 1 power operated vehicle (K0801).  You asked the Plan to pre-approve a group 1 power operated vehicle. You say that this item is medically reasonable and necessary. The Plan denied your request. The Plan says your mobility needs can be met using a cane and walker.  The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.   The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a group 1 power operated vehicle (K0801).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says you have no skilled nursing or skilled therapy needs that can only be provided on an inpatient basis.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled nursing services are not necessary. Our reviewer found that there are identifiable skilled therapy needs but therapy is not required on a daily basis.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a shower chair.  You asked the Plan to pre-approve a shower chair. You say that this is medically necessary, as you are wheelchair-bound with end-stage arthritis in the knees, shoulders, and wrist. The Plan denied your request. The Plan says this is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.   While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Xyrem for the enrollee.  You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xyrem for the enrollee.   Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Trulicity.  

You asked the Plan to pre-approve Trulicity. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Trulicity is not covered under the enrollee's Medicare Part B benefit.  

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trulicity.  

 Benefits for Trulicity may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.