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

 We decided that the Plan does not have to pre-approve an expandable controller, expandable controller harness, electronic connection device, and power seat elevation feature for a power wheelchair.  You asked the Plan to pre-approve power wheelchair components. You say that you need these components. The Plan denied your request. The Plan says the denial of authorization for these components is correct, because there is not a medical need to control your wheelchair's power options through a joystick and a power seat elevation feature is not covered by Medicare.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that a power seat elevation feature 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 power wheelchair components. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found although there are 3 approved power options on this wheelchair, there is not a medical need to control these power options through the requested joystick. Documentation shows that you are able to independently bathe, dress, groom, feed, and toilet yourself. Upper limb strength and function are adequate for you to be able to control the power options using their own switches included in the allowance of the power options.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power wheelchair components have not been met. Furthermore, the requested power seat elevation feature is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve an expandable controller, expandable controller harness, electronic connection device, and power seat elevation feature for a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve dialysis services to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the dialysis services. You say that you would like reconsideration because you are in the process of contracting with the Plan. The Plan denied your request. The Plan says there are in-network providers available to render this care.  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 dialysis services 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 pre-approve a dental consultation with an endodontist.  You asked the Plan to pre-approve consultation visit. You say that every time you drink something hot or cold you have pain. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because services performed by an endodontist are not covered by the Plan's dental benefits.  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 performed by an endodontist. Therefore, we decided that the Plan does not have to pre-approve a dental consultation with an endodontist.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve laminotomy surgery.  You asked the Plan to pre-approve laminotomy surgery. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee does not meet the criteria for this surgery.  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 laminotomy surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of adequate conservative measures for neck pain including physical therapy. More conservative measures are needed.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of laminotomy surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve laminotomy surgery.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a cardiac loop recorder.  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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no documentation of a medical evaluation for loss of consciousness (syncope) or heart palpitations. There is no documentation of electrocardiogram (EKG) monitoring to establish a definite diagnosis or to confirm irregular heartbeat (arrhythmia) as a cause of your symptoms. There is no evidence to support you have an increased risk of serious cardiac arrhythmia. The services are therefore not reasonable or medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a cardiac loop recorder.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the eye exam and diagnostic services to be provided by an OON provider.  You asked the Plan to pre-approve the eye exam and diagnostic services. You say that you need to see this out-of-network doctor because you are not getting the treatment you need. 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 eye exam and diagnostic services to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a gym membership.  You asked the Plan to pre-approve a gym membership. The Plan denied your request. The Plan says your Plan does not include a gym membership as a supplemental benefit.  The Plan must follow Medicare rules. The rules say that Medicare does not cover gym benefits.   The services at issue in this appeal are gym benefits. Therefore, we decided that the Plan does not have to pre-approve a gym membership.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after November 18, 2021.  You asked the Plan to pre-approve SNF care. You say that you were improving with therapy and disagree with this denial. The Plan denied your request. The Plan says the denial of authorization for continued SNF care after November 18, 2021 is correct.  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 services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after November 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the vasopneumatic device therapy and therapeutic injections provided on October 12, 2020.  You asked the Plan to pay for the vasopneumatic device therapy and vitamin injections. You say that the records demonstrate the medical necessity of the service and the documents prove the services are not experimental/investigational. You say that the treatment is appropriate for the patient's medical condition made no misrepresentation to induce incorrect payment. The Plan denied your request. The Plan says this treatment is experimental/investigational.   The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law. Medicare rules also say that in order for physician-provided drugs to be covered, the medical records must document the name of the drug administered as well as the dosage.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the vasopneumatic device therapy and therapeutic injections have not been met. Specifically, the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy. In addition, payment for CPT codes 96372 is not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Therefore, we decided that the Plan does not have to pay for the vasopneumatic device therapy and therapeutic injections provided on October 12, 2020.
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 the SNF services. You say that the medical records provided support the need for continued SNF care. The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval. The Plan says that the enrollee has no noted daily skilled complex nursing or therapy needs.  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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found, at the time of admission, the enrollee required skilled rehabilitation services to improve function due to weakness and deconditioning. There were no skilled nursing needs. As of November 25, 2021, the enrollee did not require any skilled nursing or rehabilitation services on a daily basis.  She was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living.  The enrollee did not require skilled therapy to establish a safe and effective maintenance program.  As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care as of November 25, 2021. The enrollee did not have any parental medications, complex wound care or nutrition given via a feeding tube.  The member received skilled care and improved; however, her function had plateaued by 11/25/2021 and she did not require any further inpatient skilled rehabilitation services. The enrollee's function was at or near her prior level of function and she could be discharged to a lower level of care for further services.  As of November 25, 2021, the enrollee required custodial 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 the 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve crowns (D2750) for teeth # 18, 19, 20, and 21.  You asked the Plan to pre-approve the dental services. You say that your bridge is no longer in good condition. You say that this makes it uncomfortable for you to eat. You also say that you have had your bridge for over 20 years. The Plan denied your request. The Plan says the crowns are not covered 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. The Plan covers the dental services when the services are medically necessary and reasonable.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the file does not include the required supporting documentation to show that the requested services are necessary. Therefore, we decided that the Plan does not have to pre-approve crowns (D2750) for teeth # 18, 19, 20, and 21.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a home ventilator.  You asked the Plan to pre-approve a home ventilator. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested device is not medically necessary.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says that the documentation does not support that the requested home ventilator is medically reasonable or necessary. Our physician reviewer found you have a diagnosis of Chronic obstructive pulmonary disease (COPD), but there is no documentation of chronic carbon dioxide (CO2) retention on arterial blood gases while awake and stable. You suffered an episode of acute respiratory failure likely secondary to morphine administration for pain.  Furthermore, Medicare does not cover a ventilator when used as BiPAP. Therefore, you do not meet criteria for the requested ventilator.  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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the abdomen and pelvis you had at an outpatient hospital facility on May 28, 2021.  You asked the Plan to waive the copayment for the CT scan. You say that you believe this was done in your primary care provider's office. The Plan denied your request. The Plan says you were charged this copayment 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 $275 copayment for advanced imaging in an outpatient hospital.   You have been asked to pay a $275 copayment for the CT scan. We have confirmed that the facility where you received this CT scan bills as an outpatient hospital facility. The CT scan falls within the advanced imaging in an outpatient hospital 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 the computed tomography (CT) scan of the abdomen and pelvis you had at an outpatient hospital facility on May 28, 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 clinical documentation provided supports the request for LTACH care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee can safely receive the services needed in another setting.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 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 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve incontinence supplies.  You asked the Plan to pre-approve incontinence supplies. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable.   While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 48 additional trips for routine transportation.  You asked the Plan to pre-approve 48 additional trips. You say that the enrollee requires frequent transportation to office visits. The Plan denied your request. The Plan says the requested number of trips exceeds the limit listed by the Plan.  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 48 trips per year.   We looked at your request, the records in the case file, and the rules. The Plan provided documentation verifying that the enrollee has used all of the available trips for 2021. Based on this information, we decided that the enrollee has exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 48 additional trips for routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140), removal of residual tooth roots (D7250), and deep sedation (D9222, D9223) provided on June 14, 2021.  You asked the Plan to pay for the dental services. You say that you were in a lot of pain. You say that your dentist would not treat you because you were on blood thinners. You say that you were sent to an oral surgeon. You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for dental services received from 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.  Though the Plan offers a dental benefit in excess of Medicare coverage, dental services received from a provider that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), removal of residual tooth roots (D7250), and deep sedation (D9222, D9223) provided on June 14, 2021.