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

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
You asked the Plan to pre-approve a pneumatic compression device. You say that the item should be covered. The Plan denied your request. The Plan says the enrollee has not been compliant with past therapies and non-segmental compression has not been tired nor does the member have edema that extends into the abdomen.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 3.

You asked the Plan to pre-approve the dental service. You say that the core build up is medically necessary. The Plan denied your request. The Plan says core build up is not listed as a covered service.

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 core build up is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).

You asked the Plan to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs). The Plan denied your request. The Plan says the certification dated August 30, 2021 documented that the enrollee has none of the qualifying diagnoses, does not require intense care coordination, and has no high risk for hospitalizations or high risk for adverse health outcomes.

The Plan contract says that, in order to be eligible for special supplemental benefits for the chronically ill, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination. 

We looked at the file and Plan's rules. The file shows that your medical conditions are not eligible medical conditions for coverage under the Plan's benefit. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).
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 would like the IRF admission covered. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements for approval.

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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement portable oxygen concentrator (E1392).

You asked the Plan to pre-approve a portable oxygen concentrator. You say that your current oxygen concentrator is not holding a charge and you were told the device is obsolete. The Plan denied your request. The Plan says rules for coverage for durable medical equipment have not been met.

The Plan must follow Medicare rules. Medicare rules say that, in the absence of program instructions, the reasonable useful lifetime of equipment in no case can be less than 5 years. Computation of the useful lifetime is based on when the equipment is delivered to the enrollee, not the age of the equipment. 

We looked at the file and Medicare rules. In this case, you are requesting a replacement for a portable oxygen concentrator. The Plan has indicated that you are eligible for a replacement in March 2022. Therefore, the requested replacements are for items that have not outlasted their reasonable useful lifetime. Based on this information, we decided that Medicare rules for coverage of a portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement portable oxygen concentrator (E1392).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #5 and core buildup, including any pins when required (D2950) for tooth #5.
You asked the Plan to pre-approve the crown and core buildup. You say that the enrollee has a large old composite filling on tooth #5 that is cracked and leaking bacteria into the tooth. You also say that these services are medically necessary to save tooth #5. The Plan denied your request. The Plan says these services exceed the maximum counts allowed per period.
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, crown (D2740) and core buildup, including any pins when required (D2950) are each limited to one procedure per tooth every five plan years. The record shows that the enrollee received a crown (D2740) on tooth #5 and core buildup, including any pins when required (D2950) on tooth #5 on June 16, 2021 and the enrollee's crown (D2740) and core buildup,
including any pins when required (D2950) benefits for tooth #5 have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth #5 and core buildup, including any pins when required (D2950) for tooth #5.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says this item is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 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 A6549
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removal of torus palatinus (D7472).

You asked the Plan to pre-approve the removal of torus palatinus. The Plan denied your request. The Plan says
this service is not covered under your benefit 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 pre-approve a
removal of torus palatinus (D7472).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on March 15, 2021.
You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says the Plan only
covers hearing aids purchased through the Plan hearing aid vendor.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when purchased through the Plan hearing aid vendor.
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provide by the Plan's
hearing aid vendor. Based on this information, we decided that the Plan's rules for coverage of the hearing aids
have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on
March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the neurology office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the office visit. You say that you would like reconsideration because you would prefer to be seen by your requested provider. The Plan denied your request. The Plan says further management of your condition can be provided by an in-network neurologist.
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 neurology office visit to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Eylea injection.

You asked the Plan to pre-approve Eylea, Injection, aflibercept, 1 mg (J0178) and intravitreal injection of a
pharmacologic agent (separate procedure) (67028). You say that there are documented cases of eye infections
from using Avastin due to sterility concerns. The Plan denied your request. The Plan says that the enrollee has
not first tried Avastin, Mvasi or Zirabev.

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 Eylea, Injection, aflibercept, 1 mg
(J0178) and intravitreal injection of a pharmacologic agent (separate procedure) (67028). Our reviewer says
that the patient has not tried and failed the required drug(s). Additionally as stated in Drugdex/Micromedex:
"Aflibercept was associated with a significantly lower mean number of injections (3.72 vs 5.44) and a longer
period between injections (54.23 vs 35.12 days) compared with bevacizumab in a 12-month randomized study
in patients with macular edema secondary to central retinal vein occlusion (N=79 eyes in 79 patients).
Significant improvements from baseline in best corrected visual acuity (BCVA) and central foveal thickness
occurred in both aflibercept and bevacizumab groups with no significant between-group difference. Aflibercept
resulted in a significantly greater proportion of eyes demonstrating improvement in nonperfusion (75% vs
36.5%)". Our physician reviewer found Eylea is approved by the Food and Drug Administration for the
treatment of macular edema secondary to central retinal vein occlusion; the plan's required drug(s) are not.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Eylea, Injection, aflibercept, 1 mg (J0178) and intravitreal injection of a
pharmacologic agent (separate procedure) (67028) have been met. Therefore, we decided that the Plan has to
pre-approve Eylea injection.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
You asked the Plan to pre-approve the compression stockings. You say that this item is medically necessary for
your condition. The Plan denied your request. The Plan says there is no qualifying wound as required for
coverage of the requested equipment.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that
compression bandages and gradient compression wraps are covered only when they are used as dressings over
a qualifying wound.
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you
do not have a medical condition for which compression stockings can be covered or paid for by Medicare.
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code
A6545.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on May 8, 2021.

You asked the Plan to pay for ambulance response and treatment, no transport. You say that you called an ambulance for help as you could not get up and you did not realize that you would have to pay $150.00 for their help. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on May 8, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on May 8, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on April 8, 2021.

You asked the Plan to waive the copayment for an ultrasound. You say that you have never paid more than a $10 copayment before and disagree with the higher charges. 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 $100 copayment for ultrasounds. 

You have been asked to pay a $100 copayment for an ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound provided on April 8, 2021.
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 of intraoral x-rays (D0210) provided on June 3, 2021.
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You
say that these services were provided due to an emergency and you would like them to be covered. The Plan
denied your request. The Plan says these services exceed the maximum counts allowed per period.
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, comprehensive oral evaluation
(D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan
years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of
intraoral x-rays (D0210) on May 20, 2019, and your comprehensive oral evaluation (D0150) and complete
series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does not
have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210)
provided on June 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
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 the enrollee has lumbar spinal stenosis. The requested Superion spacer is considered experimental in nature, as more research is needed to show safety and efficacy. 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 Vertiflex Superion spacer.
The Plan references National Coverage Determination (NCD) 150.13 in their determination; however, this NCD is not binding for the services at issue and was not used in the Maximus determination.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation (G0283) traction of the lumbar region (97012) provided June 4, 2021 to June 10, 2021.
You asked the Plan to pay for the chiropractic services. You say that you had a serious spinal injury from a slip and fall. There is only one chiropractic clinic in your area. Please reconsider this payment. The Plan denied your request. The Plan says these services are not covered benefits. Only manipulation of the spine to correct subluxation is covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for electrical stimulation (G0283) traction of the lumbar region (97012) provided June 4, 2021 to June 10, 2021.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to waive the copayments for transportation services provided from May 24, 2021, to June 1, 2021.

You asked the Plan to waive the copayments for transportation services. You say that you did not receive the services and cancelled the trips. The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide medical records nor any other documentation substantiating their decision. Without these records we cannot determine whether or not transportation services took place. Therefore, we decided that the Plan has to waive the copayments for transportation services provided from May 24, 2021, to June 1, 2021.

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.