Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal care services (T1019).
You asked the Plan to pre-approve personal care services. You say that you would like this service to be
approved for coverage. The Plan denied your request. The Plan says documentation was not provided to
confirm that you meet the qualifying criteria for coverage. The Plan also says that the documentation does not
support you being enrolled in the personal home helper benefit.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is
due and the amount of payment.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of personal care services have not been met. The record shows that the Plan made attempts to reach
your health care provider but were not able to receive documentation. Therefore, we decided that the Plan does
not have to pre-approve personal care services (T1019).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation services.
You asked the Plan to pre-approve genicular nerve radiofrequency ablation services. You say that the enrollee has had this injection before and had great pain relief. You say that research indicates that this procedure is very beneficial for function and pain one year out from procedure. The Plan denied your request. The Plan says the requested procedure is still being studied to see if it is as good or better than standard treatment for knee pain from osteoarthritis.
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 genicular nerve radiofrequency ablation services. Our reviewer says that genicular nerve radiofrequency ablation services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of chronic left knee pain. The enrollee failed treatment with medication including, opiates, a home exercise program, and genicular nerve blocks. Genicular nerve blocks and genicular nerve ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a
treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular nerve radiofrequency ablation services have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intravenous moderate (conscious) sedation/analgesia (D9239 and D9243) provided on July 22, 2021.
You asked the Plan to pay for the intravenous moderate (conscious) sedation/analgesia. You say that you could not have had the extractions done without anesthesia because you cannot have local anesthetic. The Plan denied your request. The Plan says these services are not covered.
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 intravenous moderate (conscious) sedation/analgesia (D9239 and D9243) provided on July 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultraviolet (UV) light therapy system.
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied your request. The Plan says that you do not have a diagnosis of psoriasis.
The Plan must follow Medicare rules. The rules say that ultaviolet cabinets are covered for selected patients with generalized intractable psoriasis. We looked at the file and Medicare rules. The file shows that the UV light box therapy is being requested to treat atopic dermatitis. This is not a condition for which Medicare covers these services. Therefore, we decided that the Plan does not have to pre-approve an ultraviolet (UV) light therapy system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gingivectomy (D4212) and a comprehensive orthodontic treatment (D8090) provided by a participating provider
You asked the Plan to pre-approve a gingivectomy and a comprehensive orthodontic treatment. You say that you would like approval for these services. The Plan denied your request. The Plan says these are not covered 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 pre-approve a gingivectomy (D4212) and a comprehensive orthodontic treatment (D8090) provided by a participating provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that the enrollee has a congenital condition that
causes a varus deformity of his left foot and ankle that is correctable. The Plan denied your request. The Plan
says this item is not a covered benefit. Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
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 plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
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 the enrollee was admitted for surgical management of right femoral artery thrombosis, anemia, and gastrointestinal bleeding. The enrollee's medical problems are stable. There are no
complex nursing or rehabilitation needs. 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. The enrollee's care needs can be met at a lower level of care. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for lab services you received from an out-ofnetwork
provider on April 7, 2021.
You asked the Plan to waive the deductible for the out-of-network lab services. You say that you have gotten
these services in the last and didn't have to pay anything. The Plan denied your request. The Plan says you had
not yet met your out-of-network deductible at the time you received these services, so you were charged this
amount correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $250 deductible which applies to out-of-network services.
You received these lab services from an out-of-network provider. The Plan has followed Medicare rules by
clearly disclosing in the contract that there is a $250 deductible which applies to out-of-network services. This
cost sharing is a contractual obligation that had not been met at the time the out-of-network lab services were
received on April 7, 2021. Therefore, we decided that the Plan does not have to waive the deductible for lab
services you received from an out-of-network provider on April 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a leadless pacemaker for the enrollee.
You asked the Plan to pre-approve a leadless pacemaker. You say that this is medically necessary for the
enrollee. The Plan denied your request. The Plan says that there is no documentation supporting the fact that
this patient is currently part of or enrolled in any clinical study.
The Plan must follow Medicare rules. Medicare limits coverage of leadless pacemakers to those provided
within a study.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a leadless pacemaker have not been met. Specifically, there was no documentation that the leadless
pacemaker is being provided as part of a Medicare-approved study. This service is not covered unless part of a
Medicare-approved study. Therefore, we decided that the Plan does not have to pre-approve a leadless
pacemaker for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the services you received at a sleep clinic on June 11, 2021.
You asked the Plan to waive the deductible for the sleep clinic services. You say that you had these services in an office, not a hospital, so you don't believe the charge is correct. The Plan denied your request. The Plan says you were assessed this deductible correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $400 in-network deductible which applies to all services except for health and wellness education programs, worldwide coverage, and COVID-19 tests and treatment. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $400 in-network deductible which applies to the sleep clinic services you received. This deductible applies regardless of where these services were rendered. The only services for which the deductible does not apply are health and wellness education programs, worldwide coverage, and COVID-19 tests and treatment. The sleep clinic services you received do not fall in any of these categories. This cost sharing is a contractual obligation that had not been met at the time the sleep clinic services was received on June 11, 2021. Therefore, we decided
that the Plan does not have to waive the deductible for the services you received at a sleep clinic on June 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electro-acupuncture device.
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 covered.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the
Plan's rules apply in this case.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of
the acupuncture services have not been met. Specifically, the file shows that the services are being requested
for the treatment of chronic foot pain. Therefore, we decided that the Plan does not have to pre-approve an
electro-acupuncture device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ranolazine ER 500 mg tablets.
You asked the Plan to pre-approve Ranolazine ER. You say that this requested drug is medically reasonable and necessary. The Plan denied your request. The Plan says this drug is not 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 Ranolazine ER 500 mg tablets.
Benefits for Ranolazine ER 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 mileage for routine transportation (A0170).
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need to get to your medical appointment. The Plan denied your request. The Plan says your benefit only allows 12 one-way trips with each one-way trip not exceeding 50 miles of driving distance.
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 routine transportation when the driving distance for a one-way trip is within 50 miles.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Plan's rules for coverage of routine transportation have not been met. Specifically, the provider is
located 86 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we
decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 8 and 9.
You asked the Plan to pre-approve the crowns. You say that you cannot eat or chew because there are not two
front teeth. The Plan denied your request. The Plan says this service is allowed one time every 60 months. The
Plan also says that you received this service less than 60 months ago.
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, crowns are limited to once per tooth per 60 months. The record shows that you received crowns on tooth #'s 8 and 9 on October 29, 2018 and your crowns benefit for tooth #'s 8 and 9 has been exhausted. Therefore, we decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 8 and 9.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services an inpatient hospital
stay provided on May 5, 2021.
You asked the Plan to waive the copayment for ambulance services. You say that you required the services due
to complications following a colonoscopy. 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 $225
copayment for ambulance services.
You have been asked to pay a $225 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
an inpatient hospital stay provided on May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids from an out-of-network provider.
You asked the Plan to pre-approve the hearing aids. You say that you want permission to purchase hearing aids out-of-network for $500 but the Plan is compelling you to buy hearing aids for $10,000. You say that you are being forced to spend $9,500 above the yearly allowance. The Plan denied your request. The Plan says hearing aids from an out-of-network provider are not medically necessary.
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 they are received from a network provider.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Specifically, the requested provider is out-of-network. Therefore, we decided that the Plan does not have to pre-approve hearing aids from an out-of-network provider.
Your complaint about this fraudulent method 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: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care for the enrollee.
You asked the Plan to pre-approve SNF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that that the enrollee's needs can be safely met at a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that SNF care is medically reasonable and necessary for the enrollee. The enrollee does not have documented skilled nursing needs. The enrollee does have documented skilled therapy needs. The enrollee is functioning below her prior baseline, and documentation does not yet show that the enrollee has reached a new plateau in function. The enrollee's new non-weight-bearing status warrants transfer training. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the enrollee's condition does meet Medicare criteria for SNF care. 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 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 the cardiovascular risk assessment testing provided on April 21, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that coverage for all CV risk assessment panels, except the basic lipid panel, is denied for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. Per LCD L36358, the requested cardiovascular risk assessment panel is not a covered service. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on April 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on June 4, 2021
You asked the Plan to waive the copayment for [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"]. You say that you were told that there would be no charge for this transport because the hospital was not able to accept you due to lack of beds. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this transport ($222.32) is less than your copayment obligation, you are responsible for the full allowed 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 $250 copayment for ambulance services.
You have been asked to pay a $250 copayment for [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"]. This cost sharing applies regardless of the reason for the transport. 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 you received on June 4, 2021