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

 We decided that the Plan does not have to pre-approve a disposable wound suction device (A9272).  You asked the Plan to pre-approve wound suction device. You say that this device is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this is not a covered item according to Medicare rules.  The Plan must follow Medicare rules. Medicare rules say that a wound suction device will be denied as statutorily noncovered.  We looked at the file and Medicare rules. This item is statutorily noncovered according to Medicare rules. Based on this information, we decided that Medicare rules for coverage of wound suction device have not been met. Therefore, we decided that the Plan does not have to pre-approve a disposable wound suction device (A9272).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospice routine home care; per diem (T2042) provided from May 1, 2021, to May 31, 2021.

You asked the Plan to pay for the hospice care. You say that the claim was not processed according to the contract as the provider is in network. You also say that the claim should be reprocessed and paid in full. The Plan denied your request. The Plan says this code is not a valid code for Medicare purposes as the Healthcare Common Procedure Coding System (HCPCS) code is assigned a status code of "I".

The Plan must follow Medicare rules. Medicare rules say that procedure code T2042 - hospice routine home care; per diem - has a Status Code of "I", indicating that this code is not valid for Medicare purposes and is not payable. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the hospice care have not been met. Therefore, we decided that the Plan does not have to pay for the hospice routine home care; per diem (T2042) provided from May 1, 2021, to May 31, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Botox injections (J0585) every 8 weeks.  You asked the Plan to pre-approve the Botox injections. You say that the injections are medically necessary at a frequency of 8 weeks. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that it is usually considered not medically necessary to give botulinum toxin injections for spastic conditions more frequently than every 12 weeks.  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 Botox injections. Our reviewer says that the injections are not medically necessary. Our physician reviewer found based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that Botox every 8 weeks for facial myokymia, hemifacial spasm meets Medicare criteria for medical necessity. The Medicare-approved major drug compendia do not support Botox dosing more frequently than every 12 weeks for hemifacial spasm.      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 Botox injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox injections (J0585) every 8 weeks.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient behavioral health services.

You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee does not have acute symptoms that require 24-hour inpatient care.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. Continued services from December 22, 2021, forward were requested. 

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 continued services. Our physician reviewer found that you were involuntarily admitted to the acute inpatient psychiatric/detoxification hospitalization with substance use mood disorder and synthetic marijuana use disorder. Based upon review the records, it was not expected that you would improve in a reasonable period of time beyond the dates in question. You were not showing any dangerousness to self or others, auditory or visual hallucinations. You were without aggressive behaviors while not showing any acute threats of safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient behavioral health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and accessories.

You asked the Plan to pre-approve a power wheelchair and accessories. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested
items.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

The file does not support that your power wheelchair will fit and can be used in your home to do all of your
activities of daily living. The home evaluation completed showed that the power wheelchair will not fit into
your bedroom and bathroom and you do not have a ramp to get into your home. This means that Medicare rules
for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a
power wheelchair and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional coverage for the surgical implant placement (D6010).  You asked the Plan to pre-approve additional coverage for the surgical implant placement (D6010). You say that you are not receiving enough to pay for the non-covered dental services. You say that you will be charged more than you can afford, and you are asking for a fast appeal. The Plan denied your request. The Plan says you only have $446.30 available for the 2021 benefit year. The Plan also says that benefits beyond the allowed $1500 annual maximum cannot be provided.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of $1,500 every year for covered dental services. You are responsible for the full charges of any additional dental services after the annual maximum is exhausted. Therefore, we decided that the Plan does not have to pre-approve additional coverage for the surgical implant placement (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implant removal (D6100).

You asked the Plan to pre-approve the implant removal (D6100). You say that you are fearful that the implants will cause additional harm to your health. You say that you have other dental work that requires the implants be removed to be completed. 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 pre-approve the implant removal (D6100).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Ilumya (J3245).  You asked the Plan to pre-approve Ilumya. You say that Ilumya is medically necessary. The Plan denied your request. The Plan says a trial of Remicade, Inflectra, or Stelara is required before alternative drugs can be considered.  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 Ilumya. Our reviewer says that Ilumya is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drugs or any reason they would be unsafe or ineffective for the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya (J3245).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.  You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered.  The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing.      Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a replacement socket to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the OON replacement socket. You say that you have previously attempted to work the in-network orthotic and prosthetic clinics and were very displeased with their care. You say that this denial takes away your right to choose where you can receive care and puts you at risk of future injury and declining health. The Plan denied your request. The Plan says medically necessary care is available in 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 multiple network providers available who can provide the item at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a replacement socket to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit with a specialist (99244) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve an office visit with a specialist. You say that you have confidence in this provider. You also say you have been wearing hearing aids for over ten years and this is the first time you have been able to hear over the phone and that this provider has the ability to adjust your hearing aids to your hearing needs. The Plan denied your request. The Plan says based on Medicare guidelines, your request to use an out of network provider for your services does not meet the requirements for approval.

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 with a specialist (99244) to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (97140, 97110) provided on June 28, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for out-of-network physical therapy. You say that these services were medically necessary, and the enrollee is entitled to receive this care. The Plan denied your request. The Plan says out-of-network services are only covered in certain limited circumstances. The services in this case were not pre-approved, urgent or emergent, and could have been performed by an in-network provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physical therapy services (97140, 97110) provided on June 28, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Colestipol 1 gm tablet.  You asked the Plan to pre-approve Colestipol. You say that the requested drug is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not among those covered by the medical 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 Colestipol 1 gm tablet.   Benefits for Colestipol 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve medial branch blocks (MBBs).  You asked the Plan to pre-approve medial branch blocks. 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 has not received 3 or more months of conservative therapy.  The Plan follows Medicare rules. Medicare rules stated that facet joint interventions may be covered under certain clinical circumstances.  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 medial branch blocks. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested medial branch blocks. Our physician reviewer found the record indicates that the enrollee has had pain for approximately two months at the time of the request and has not undertaken, nor does he have a contraindication to, a trial of conservative therapy.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of medial branch blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve medial branch blocks (MBBs).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a manual wheelchair.  You asked the Plan to pre-approve a manual wheelchair. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested item.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.   Records show that a manual wheelchair is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power seat elevation system.  You asked the Plan to pre-approve a power seat elevation system. You say that you would like to be able to grab/reach things off of shelves and not have to hurt your neck when speaking with someone. The Plan denied your request. The Plan says the requested item is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance services provided on June 26, 2021.  You asked the Plan to waive the copayment for ambulance services. You say that the services were necessary. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $385 copayment for ambulance services.   You have been asked to pay a $385 copayment for ambulance services. Ambulance services fall within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on June 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trospium chloride.

You asked the Plan to pre-approve Trospium chloride. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not among those covered under the enrollee's medical 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 Trospium chloride.

Benefits for Trospium chloride 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.

You asked the Plan to pre-approve additional routine transportation. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services exceed your benefit limit.

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 one-way trips per year.

We looked at your request, the records in the case file, and the rules. The documentation shows that you have utilized 48 one-way transportation trips. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for outpatient hospital facility visits provided from June 23, 2021, to July 13, 2021.  You asked the Plan to waive the copayments for outpatient hospital facility visits. You say that you feel that you should only owe a $45 copayment per each visit and disagree with the facility fees. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $385 copayment for each outpatient hospital visit.  You had outpatient hospital facility visits from June 23, 2021, to July 13, 2021. Therefore, you are responsible to pay a $385 copayment per each visit. However, you are only being asked to pay the total allowed amount of $808.30, which is less than the total copayment amount.    You have been asked to pay the total amount of $808.30 for outpatient hospital facility visits. Outpatient hospital facility visits fall within the outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for outpatient hospital facility visits provided from June 23, 2021, to July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy services.

You asked the Plan to pre-approve massage therapy services. You say that massage therapy should be covered under your Plan as you are diabetic, and part of the treatment is to keep your body in good condition and this includes circulation. The Plan denied your request. The Plan says a licensed massage therapist is not eligible to enroll in Medicare. Neither Medicare nor the Plan covers this service.

The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, we decided that the Plan does not have to pre-approve massage therapy services.