Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve computed tomographic angiography (CTA) abdominal aorta and
bilateral iliofemoral lower extremity runoff, (75635).

You asked the Plan to pre-approve the CTA. You say that the medical records provided support the necessity of
the requested service. The Plan denied your request. The Plan says that the requested CTA of the lower
extremity does not meet Medicare criteria and is not medically necessary for someone with no symptoms.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
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 CTA. Our reviewer says that the
requested items/services is considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee has multiple issues that necessitate the CT scan. The enrollee has a history of abdominal
aortic aneurysm status post endograft repair. This was associated with an occlusion of the right limb of the graft
and the enrollee has a left to right femoral-femoral artery bypass. Additionally, the enrollee has a decrease in
the ABIs and associated claudication. CTA is necessary to confirm successful exclusion of the aneurysm,
absence of endoleak, evaluate the status of the femoral-femoral artery bypass, and evaluate the runoff as
conventional angiography would be more risky, due to the femoral-femoral bypass. The documentation
supports the medical necessity of the study in question.

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 CTA have been met. Therefore, we decided that the Plan has to pre-approve
computed tomographic angiography (CTA) abdominal aorta and bilateral iliofemoral lower extremity runoff,
(75635).

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond October 8, 2021.

You asked the Plan to pre-approve the continued SNF care. You say that you feel that ongoing care in the SNF is necessary. The Plan denied your request. The Plan says daily skilled services are no longer required.

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 the continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a male who was hospitalized after a fall with a wrist injury and leg swelling. The enrollee was admitted to the SNF on 9/23/2021 for therapy, medical monitoring and wound care. From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. He was treated for a left leg venous ulcer and completed a course of oral antibiotics. Regarding rehabilitation services, the beneficiary received physical and occupational therapy in the SNF. By the dates in question, the beneficiary was at a contact guard to moderate assist level with functional mobility including gait to 225 feet with a rolling walker. 

There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond October 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigations (D4921) and drugs or medicaments dispensed in the office for home use (D9630) provided on May 13, 2021, and May 27, 2021.

You asked the Plan to pay for the gingival irrigations and drugs or medicaments. You say that you would not have been able to have the root scaling without having the irrigation and medication for the root scaling procedure. The Plan denied your request. The Plan says these services are not covered benefits 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 gingival irrigations (D4921) and drugs or medicaments dispensed in the office for home use (D9630) provided on May 13, 2021, and May 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the glasses provided on December 16, 2020.
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You asked the Plan to pay for the glasses. You say that your documents indicate one pair of eyeglasses with standard frames is covered by Medicare and the Plan can offer extra benefits. You say that you had the same vision reimbursement claim last year that was paid. The Plan denied your request. The Plan says the eyeglass services provided were not in relation to a cataract surgery and you do not have any additional coverage for eyeglass services per plan benefits.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan only covers one pair of eyeglasses or contact lenses after each cataract surgery.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the glasses have not been met. Specifically, the records do not show that the glasses were provided after cataract surgery. Therefore, we decided that the Plan does not have to pay for the glasses provided on December 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ophthalmology visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the ophthalmology visit. You say that you do not trust anyone to correct the cataract surgery mistake except this provider. The Plan denied your request. The Plan says the provider is 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 the ophthalmology 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 personal training sessions.

You asked the Plan to pay for personal training sessions. You say that these services are more beneficial to you and should be covered. You say you have received reimbursement for these services in previous years. The Plan denied your request. The Plan says personal training sessions are not covered by your health and wellness benefit.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers fitness facility membership, in-network classes, on-demand videos, and home-based programs when provided from an in-network facility.

The Plan's rules for coverage of gym benefits have not been met because the requested services, personal training sessions, are among the list of covered benefits. In addition, the facility is not part of the Plan's specified health and fitness network. Therefore, we decided that the Plan does not have to pay for the personal training sessions.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery.

You asked the Plan to pre-approve Vertiflex Superion device placement surgery. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Vertiflex Superion device placement surgery. 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 back pain. The Vertiflex device is 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 Vertiflex Superion device placement surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor (BPM).
You asked the Plan to pre-approve the BPM. You say that the enrollee needs this due to his chronic kidney disease. The Plan denied your request. The Plan says the enrollee is not receiving home dialysis meaning that this item is not covered.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor (BPM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a toilet safety rail.
You asked the Plan to pre-approve the rail. You say that this is a necessary item that costs less than $100. The Plan denied your request. The Plan says this is a convenience/luxury item.
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 a toilet safety rail.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral evaluation (D0120), prophylaxis (D1110), bitewing x-rays (D0274), and filling (D2391) provided from April 13, 2021, to April 28, 2021, by an out of network dentist.

You asked the Plan to pay for the dental services. You say that the preventive and comprehensive coverage were identical for in network and out of network. You also say that you would like all of the charges to be covered. The Plan denied your request. The Plan says that the claim was processed correctly. The Plan says that dental services performed out of network are paid based on the maximum allowable charge (MAC). The Plan also says that you are responsible for all fees in excess of this amount from the billed amount.

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, dental services received out of network may have a higher cost share amount. The record shows that you are responsible for any amount greater that what the plan paid the provider. This is a contractual obligation of the plan and cannot be waived. Therefore, we decided that the Plan does not have to pay for the oral evaluation (D0120), prophylaxis (D1110), bitewing x-rays (D0274), and filling (D2391) provided from April 13, 2021, to April 28, 2021, by an out of network dentist.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for surgery.

You asked the Plan to pre-approve the referral. You say that this will provide continuity of care once you move to the new area. The Plan denied your request. The Plan says in-network providers are within the time and distance standards set by Medicare.

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 surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206), or pay more for the comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), and prophylaxis (D1110) provided on May 6, 2021 by an OON provider.
You asked the Plan to pay for the topical application of fluoride varnish, and to pay more for the comprehensive oral evaluation, complete series of intraoral x-rays, and prophylaxis. You say that the topical application of fluoride varnish (D1206) only cost $39.00. You also say that you expect the Plan to cover $346.00 of the total invoice, of which $156.00 has already been paid. The Plan denied your request. The Plan says topical application of fluoride varnish is not a covered service. The Plan also says that these services were performed by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.
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, topical application of fluoride varnish is not among those covered under this benefit. You are also responsible for the difference between the billed amount and allowed amount for covered dental services that are received OON. Therefore, we decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206), or pay more for the comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), and prophylaxis (D1110) provided on May 6, 2021 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) for a power wheelchair.

You asked the Plan to pre-approve power seat elevation feature. You say that the enrollee needs this as soon as possible. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because a power seat elevation feature is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is not covered by Medicare.

We looked at the file and Medicare rules. This component is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of power seat elevation feature have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) for a power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you have not walked in 3 years and you are not getting enough therapy. You have painful muscle spasms all over your body and herniated discs. You also say your speech is getting worse. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from
February 5, 2020, to February 29, 2020.

You asked the Plan to pay for the SNF services. You say that there was less than usual billing staff. You also
say that an exception should be made due to the coronavirus. You also say that the services rendered were
necessary. The Plan denied your request. The Plan says Medicare denies a claim if it is not received by the plan
within 12 months or 1 calendar year from the date when the services were rendered. The Plan also says that this
is past the allowed 12-month timeframe.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.

The record shows that a claim for the SNF services was not filed until June 11, 2021. This means that more
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that
the Plan does not have to pay for the skilled nursing facility (SNF) care provided from February 5, 2020, to
February 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral complete series x-ray provided on June 1, 2021.

You asked the Plan to pay for the intraoral complete series x-ray. You say that you get an extra cleaning and exam with this Plan, but you were charged $79 extra. You say that you were never told there would be an extra bill and the payment should be stopped. The Plan denied your request. The Plan says the service is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral complete series x-ray provided on June 1, 2021.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.

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 enrollee appears to be improving and responding to treatment. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility for the time being. Transfer to a lower level of care may be considered when treatment has completed. 

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the add tooth to an existing partial denture (D5650) and surgical extraction (D7210) provided on May 25, 2021.
You asked the Plan to pay for the add tooth to an existing partial denture and surgical extraction. You say that the provider told you that you would only be responsible for a $35 copay for these services. The Plan denied your request. The Plan says these services are not covered. The Plan also says that you were not enrolled in the supplemental dental plan at the time of these services.
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 add tooth to an existing partial denture (D5650) and surgical extraction (D7210) provided on May 25, 2021.