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

We decided that the Plan does not have to pre-approve addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845) for the enrollee.

You asked the Plan to pre-approve the services. You say that this knee system is appropriate with L5845. The Plan denied your request. The Plan says the approved knee Ossur Total Knee 1900 does not include code L5845.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the issue is the medical necessity for accessories for prosthetic leg including a stance flexion feature. The health plan has approved a prosthetic leg with the other requested features. The requested stance flexion feature cannot be used with the other features of the approved prosthetic leg. The documentation does not support that there are extenuating circumstances that would require the authorization of the stance flexion feature.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845) for the enrollee.
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. You say that the enrollee has a chronic pathologic condition. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an air purifier (E1399).

You asked the Plan to pre-approve an air purifier. You say that you are appealing the plan's decision to deny as you need the medical equipment. The Plan denied your request. The Plan says this item is not a covered benefit.

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 an air purifier (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for pain management services (procedure code 62320) provided to the enrollee on September 13, 2021.
You asked the Plan to pay for the services. You say that the services were billed correctly and should be paid for. The Plan denied your request. The Plan says the records are insufficient to support payment for the services.
The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain documentation requirements must be met. The documentation must include the legible signature of the physician or non-physician practitioner responsible for providing the care to the patient. In addition, the procedure report should clearly document the indications and the medical necessity for the blocks along with the pre and post percent pain relief achieved immediately post-injection. The medical records in this case do not meet Medicare's documentation requirements. Specifically, there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for pain management services (procedure code 62320) provided to the enrollee on September 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required
(D2950).
You asked the Plan to pre-approve the core buildup. You say that the dentist office shows this service as a
covered and necessary part of the root canal and crown. You also say that you would like this service to be
covered so you can eat normally. The Plan denied your request. The Plan says this service is not covered by
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 pre-approve a
core buildup, including any pins when required (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the healthy groceries benefit.  

You asked the Plan to pre-approve the healthy groceries benefit. The Plan denied your request. The Plan says that the Plan has made several attempts to reach the member's health care provider and was unable to receive confirmation of the member having a chronic condition listed in chapter 4, section 2.1 of the Evidence of Coverage. The Plan was also unable to receive confirmation from the member's health care provider that the member's chronic condition could be made worse by not having or would benefit from receiving assistance with healthy groceries.  

The contract with the Plan covers a Healthy Groceries benefit. The Plan says as a Special Supplemental Benefit for the Chronically Ill, you must meet the criteria in section 2.1 of this chapter, as per CMS guidelines and provide supporting documentation from your physician identifying you as having a condition that can be made worse by not having or would benefit from receiving assistance with healthy groceries.  

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the healthy groceries benefit have not been met. Specifically, the file shows that the Plan has made several attempts to reach your health care provider and was unable to receive confirmation of you having a chronic condition listed in chapter 4, section 2.1 of the Evidence of Coverage. The Plan was also unable to receive confirmation from your health care provider that your chronic condition could be made worse by not having or would benefit from receiving assistance with healthy groceries. Therefore, we decided that the Plan does not have to pre-approve the healthy groceries benefit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Onetouch Ultra test strips.

You asked the Plan to pre-approve Onetouch Ultra test strips. You say that this is medically necessary. The Plan denied your request. The Plan says this is not one of the Plan's preferred brands.

The Plan must follow Medicare rules. Medicare rules say that Medicare Advantage (MA) plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the durable medical equipment (DME) to only those preferred brands and manufacturers, as long as the conditions listed in the rules section are met. 

We looked at the file and Medicare rules. The submitted documentation does not document a medical reason that the enrollee cannot use the Plan's preferred brands. The Plan has approved a provide a 90-day transition period for the requested brand. Based on this information, we decided that Medicare rules for coverage of Onetouch Ultra test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Onetouch Ultra test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an air purifier (E1399).  

You asked the Plan to pre-approve an air purifier. You say that you have multiple chronic health conditions. This will help you breath fresher, cleaner, better air into your lungs as well as try to keep you from relapsing and getting sicker because of the air quality you breathe. The Plan denied your request. The Plan says this time is not a covered benefit.  

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 an air purifier (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre device and supplies.
You asked the Plan to pre-approve a Freestyle Libre device and supplies. You say that the requested items are a necessity for your care. The Plan denied your request. The Plan says rules for coverage for the requested items have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre device and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre device and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on September 21, 2021.
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you had x-rays done and you were under the impression that they were covered at no cost to you. The Plan denied your request. The Plan says this service is not a covered expense under your dental plan. The Plan also says that you did not contact the Plan prior to the date of service to verify 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. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on September 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist office visit (99205) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a specialist office visit. You say that you had been receiving pain management care with no success, prior to your primary care physician's suggestion that you see care through this provider. The Plan denied your request. The Plan says the enrollee has access to multiple in-plan providers that can provide the same services and treatment for his condition. The Plan also says that it is not medically necessary to seek care with a non-contracted 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 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 a specialist office visit (99205) 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 implant placement (D6010 x 7), abutment supported crowns (D6059 x 3), and custom abutments (D6057 x 7).
You asked the Plan to pre-approve the dental services. You say that you do not have any teeth. You say that you cannot eat. You say that your bridge was knocked out. You also say that it is painful for you to eat. The Plan denied your request. The Plan says dental implants and all associated services are excluded from coverage.
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 implant and associated services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve implant placement (D6010 x 7), abutment supported crowns (D6059 x 3), and custom abutments (D6057 x 7).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the device for monitoring purposes is not reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation does not indicate that the enrollee requires frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a total knee arthroplasty using the Mako robot/computed tomography (CT) scan for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that medical studies do not support the use of this scan.

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 services. Our reviewer says that the requested imaging is medically reasonable and necessary. Our physician reviewer found the use of the Mako robotic device requires CT scanning for preoperation planning according to the protocol offered by the manufacturer. If this device is to be used for the procedure the requested CT is 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 the services have been met. Therefore, we decided that the Plan has to pre-approve a total knee arthroplasty using the Mako robot/computed tomography (CT) scan for the enrollee.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81001) provided on September 7, 2021,
by an out-of-network (OON) provider.
You asked the Plan to pay for laboratory services. You say that you do not receive any patient information until
after services are rendered. You also say this patient was seen by an in-network physician with no control over
the laboratory used and should not be penalized by having this claim processed as out of network. The Plan
denied your request. The Plan says this provider is not a network provider with the Plan. The services were not
referred by a network provider or rendered in a participating facility. The Plan also says that they have also
determined that these services are not urgent or emergent, nor were they approved in advance.
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 laboratory services (81001) provided on
September 7, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on September 23, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the provider must first
bill the primary insurer.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to bill the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the services provided on September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pain management services (procedure code 62320) provided to the enrollee on October 11, 2021.
You asked the Plan to pre-approve the services. You say that the services were billed correctly and should be paid for. The Plan denied your request. The Plan says the records are insufficient to support payment for the services.
The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain documentation requirements must be met. The documentation must include the legible signature of the physician or non-physician practitioner responsible for providing the care to the patient. In addition, the procedure report should clearly document the indications and the medical necessity for the blocks along with the pre and post percent pain relief achieved immediately post-injection. The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve pain management services (procedure code 62320) provided to the enrollee on October 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral radiographic imaging (D0210) provided by an
out-of-network provider on September 23, 2021.
You asked the Plan to pay for an intraoral radiographic imaging. You say that you were told that this provider
was in-network. The Plan denied your request. The Plan says the benefit limit for D0210 has already been
exhausted.
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 an intraoral
radiographic imaging once every three years.
We looked at the file and Medicare rules. Evidence was provided to show that D0210 was provided on May 20, 2021. Based on this information, we decided that the Plan's rules for coverage of an intraoral radiographic imaging have already been met. Therefore, we decided that the Plan does not have to pay for an intraoral radiographic imaging (D0210) provided by an out-of-network provider on September 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for pulpal debridement (D3221) for tooth # 14.
You asked the Plan to pay for the dental service. You say that this authorization should be covered because it is medically necessary. You also say that your dentist advised you need this service before your root canal can be completed. The Plan denied your request. The Plan says pulpal debridement 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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for pulpal debridement (D3221) for tooth # 14.