Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

e decided that the Plan does not have to pay for a filling (D2392) provided on June 30, 2021.
You asked the Plan to pay for a filling. You say that you were told by the provider that you could have 3
fillings covered in full. The Plan denied your request. The Plan says the service is a covered benefit, but you
have exceeded the frequency limit of 2 per calendar year.
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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a filling have not been met. Specifically, the record shows that you had exceeded the frequency
limit for this service. Therefore, we decided that the Plan does not have to pay for a filling (D2392) provided
on June 30, 2021. Your complaint about the potential misinformation you received from the provider is not a valid appeal for
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does
not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Comprehensive Cardiovascular (CV) Panel provided on
April 28, 2021.
You asked the Plan to pay for the Comprehensive Cardiovascular Panel. You say that you would like
reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says
there is no Medicare benefit for screening CV risk assessment testing for asymptomatic (without signs or
symptoms of disease) patients.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, the Comprehensive Cardiovascular Panel, was requested solely for screening
purposes. Medicare does not cover this test solely for screening purposes. Additionally, no clinical information
has been submitted to verify if the member was symptomatic. Therefore, we decided that the Plan does not
have to pay for the Comprehensive Cardiovascular (CV) Panel provided on April 28, 2021.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve myocardial perfusion imaging Single Photon Emission Computed
Tomography (SPECT) (78452).
You asked the Plan to pre-approve SPECT. You say that you disagree with the Plan's denial. The Plan denied
your request. The Plan says that the enrollee does not meet criteria for coverage.
The Plan follows Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or
service, then that item or service will be covered when it is 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 SPECT. Our reviewer says that the
enrollee meets the medical necessity and reasonableness criteria for us of SPECT imaging in this case. Our
physician reviewer found the enrollee has a high pre-test probability for ischemic heart disease, especially
given her insulin dependent diabetes, which is a CAD equivalent. A more sensitive test would be recommended
in this instance in order to avoid a false negative finding in a patient with high pre-test probability of disease.
SPECT nuclear would fulfill these criteria as opposed to standard EKG exercise testing. In addition, she has
several musculoskeletal issues including hip tendonitis, back pain and fibromyalgia making it unlikely she
would be able to exercise to a predictive heart rate and that pharmacologic nuclear SPECT testing would be
needed for a diagnostic study.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SPECT have been met. Therefore, we decided that the Plan has to pre-approve
myocardial perfusion imaging Single Photon Emission Computed Tomography (SPECT) (78452).
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Renflexis for the enrollee.
You asked the Plan to pre-approve Renflexis. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no indication Stelara would likely be less effective, and/or cause adverse effects for the member.
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 Renflexis. Our reviewer says that Renflexis is not medically reasonable and necessary for the enrollee. The patient has not tried and failed Stelara. There is no documentation provided indicating that Stelara would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Renflexis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Renflexis have not been met. Therefore, we decided that the Plan does not have to pre-approve Renflexis for the enrollee.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you are weak and unable to stand. The Plan denied your request. The Plan says that you do not have skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient.
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 physician reviewer found that you require extensive assistance with mobility. Although you do not have any skilled nursing needs, you have had a significant decline in physical functioning. You do require skilled therapy services on a daily basis at a skilled nursing facility to restore function and avoid further decline or complications. Therefore, admission to a skilled nursing facility for inpatient rehabilitation services is medically appropriate. 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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 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 a transport chair for the enrollee.

You asked the Plan to pre-approve a transport chair. You say that the current wheelchair is broken. The Plan denied your request. The Plan says the durable medical equipment provider confirmed the enrollees spouse stated they needed a transport chair as they cannot lift the current wheelchair into the car. The provider stated repairs are not needed to the current chair.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. Duplicate equipment is covered. The enrollee has a manual wheelchair for use in the home. Medicare and the Plan do not cover additional equipment for convenience or for use outside of the home. Therefore, we decided that the Plan does not have to pre-approve a transport chair for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic therapy (D3310), a filling (D2332), an intraoral periapical radiographic image (D0220), a limited oral evaluation (D0140), a crown (D2740), and a prefabricated post and core (D2954) provided from March 17, 2021, through April 21, 2021.

You asked the Plan to pay for endodontic therapy, a filling, an intraoral periapical radiographic image, a limited oral evaluation, a crown, and a prefabricated post and core. You say that the services were necessary, and you could not get an appointment with an in-network provider. The Plan denied your request. The Plan says you are not covered for these services when seen by an out-of-network provider.

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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of endodontic therapy, a filling, an intraoral periapical radiographic image, a limited oral evaluation, a crown, and a prefabricated post and core have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for endodontic therapy (D3310), a filling (D2332), an intraoral periapical radiographic image (D0220), a limited oral evaluation (D0140), a crown (D2740), and a prefabricated post and core (D2954) provided from March 17, 2021, through April 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LED lights for the enrollee.
You asked the Plan to pre-approve LED lights. You say that this equipment is medically necessary for the Plan.
The Plan denied your request. The Plan says while the wheelchair was approved, LED lights are not covered by
Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose. LED lights do 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 LED lights for the enrollee.
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 LTACH services are medically
necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee was admitted following acute on chronic respiratory failure due to
pulmonary infection. The enrollee continues to receive aggressive pulmonary therapy and intravenous
antibiotics. The enrollee continues to receive acute care services, and these have not been denied. The
enrollee's meets are met in the current setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the 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 pay for a vacuum erection system (L7900).
You asked the Plan to pay for a vacuum erection system. You say that this has been covered in the past. The
Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that vacuum erection devices (L7900) and related
accessories (L7902) are statutorily non-covered.
We looked at the file and Medicare rules. The requested item is not covered. Based on this information, we
decided that Medicare rules for coverage of a vacuum erection system have not been met. Therefore, we
decided that the Plan does not have to pay for a vacuum erection system (L7900).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuous glucose monitor Freestyle Libre.

You asked the Plan to pre-approve the Freestyle Libre. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria as the enrollee is not insulin treated with multiple (3 or more) daily injections of insulin or a Medicare covered continuous subcutaneous insulin infusion (CSII) pump.

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 the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of the Freestyle Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuous glucose monitor Freestyle Libre.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional extractions provided on December 30, 2020.

You asked the Plan to pay for the additional extractions. You say that you were informed the service was
covered. You say that you request a review of the decision as it is contrary to the information you were
provided at the time of service. The Plan denied your request. The Plan says reimbursement was already issued
for one extraction.

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 Plan is only obligated to pay for
one extraction per calendar year from an in-network provider. The Plan paid for one extraction provided on
December 30, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay
for the additional extractions provided on December 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Promacta for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that this is not covered under Part B. 
 
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 Promacta for the enrollee.  
 
Benefits for this drug 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a limited oral evaluation - problem focused (D0140) and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) performed by an oral surgeon.
You asked the Plan to pre-approve a limited oral exam and tooth extraction performed by an oral surgeon. You say that you are in pain and need the services performed by an oral surgeon. The Plan denied your request. The Plan says the limited oral exam is not a covered service and tooth extractions are not covered when performed by an oral surgeon.
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 one tooth extraction per year when performed by a participating general dentist.
We looked at the file, and Medicare rules. In this case the tooth extraction is requested to be performed by an oral surgeon. Based on this information, we decided that the Plan's rules for coverage of a tooth extraction have not been met. Though the Plan offers dental benefits in excess of Medicare coverage, the limited oral exam is not among those covered services. Therefore, we decided that the Plan does not have to pre-approve a limited oral evaluation - problem focused (D0140) and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) performed by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.

You asked the Plan to pre-approve a portable ventilator. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that ventilators (E0465, E0466, and E0467) are covered for specific conditions. 

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 portable ventilator. Our reviewer says that the services are not medically necessary. Our physician reviewer found the provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. You could be treated with a bilevel positive airway pressure (BiPAP) machine with average volume assured pressure support (AVAPS) capability. The plan has indicated such a device is covered. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 

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 portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on April 7, 2021
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The 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 physician services provided to the enrollee on April 7, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trivisc.

You asked the Plan to pre-approve these services. You say that the step therapy requirement is not met. The Plan denied your request. The Plan says the services are not medically necessary.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has knee pain due to osteoarthritis. He has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not show that the required drugs would be contraindicated or less effective; therefore, Trivisc is 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 Trivisc.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the 20% coinsurance for Medicare Part B drugs provided from July 25, 2019, to January 25, 2021.
You asked the Plan to waive this coinsurance. You say that you do not believe this coinsurance is correct. The Plan denied your request. The Plan says this coinsurance was charged based on the type of drug treatment provided and the Plan contract agreement.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Each Plan contract with the Plan clearly says that enrollees pay 20% coinsurance for Medicare Part B drugs. The enrollee has been asked to pay the correct amount based on each year's contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 20% coinsurance for Medicare Part B drugs provided from July 25, 2019, to January 25, 2021.