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

We decided that the Plan does not have to pay for the adjunctive procedure (D9999) provided on May 6, 2021.

You asked the Plan to pay for the adjunctive procedure. You say that your plan booklet shows you have up to $1,000.00 in dental coverage and that you can go to any dentist. You also say that it is a once-a-year thing to replace the little gaskets in your denture implants. The Plan denied your request. The Plan says you do not have any routine dental benefits and are not eligible for coverage. The Plan also says that you only have dental benefits through the dental rider, which was not active at the time of service.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the adjunctive procedure (D9999) provided on May 6, 2021.
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 LTACH Admission is medically
necessary. The Plan denied your request. The Plan says the enrollee can receive the same services at the current
level of care.
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 documentation does not support that the enrollee in this case requires services at
the LTACH that are not available at the acute care hospital where he is currently receiving care.
There are no required medical services identified that are available at the LTACH, that are not available at the
current health care setting being offered by the health plan.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint fusion (27279).

You asked the Plan to pre-approve sacroiliac joint fusion. You say that this is medically necessary because the
enrollee has failed other treatments. The Plan denied your request. The Plan says there is insufficient evidence
to support this.

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 sacroiliac joint fusion. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no documented sacroiliac degenerative joint disease or instability on imaging.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of sacroiliac joint fusion have not been met. Therefore, we decided that the Plan
does not have to pre-approve sacroiliac joint fusion (27279).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Volara system (E1399).

You asked the Plan to pre-approve the Volara system. You say that the service should be covered. The Plan
denied your request. The Plan says this service is considered experimental and investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We asked our 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 Volara system. Our reviewer says that the
requested items/services are not considered reasonable and necessary in this case. Our reviewer found this
service is considered experimental and investigational.

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 Volara system have not been met. Therefore, we decided that the Plan does
not have to pre-approve the Volara system (E1399).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration (20939).
You asked the Plan to pre-approve bone marrow aspiration. You say that this is medically necessary. The Plan denied your request. The Plan says this has not proven effective.
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 bone marrow aspiration. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollee's medical condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration (20939).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient stay provided from May 14, 2021, through May 18, 2021.

You asked the Plan to waive the copayment for the inpatient stay. The Plan denied your request. The Plan says the correct cost share was applied to the claim.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $275 copayment per day for days 1 - 6, then $0 copayment after day 6 for Inpatient Hospital Care.

The enrollee has been asked to pay a $1,100 copayment for the inpatient stay. The inpatient stay falls within the Inpatient Hospital Care benefit category. This means that the enrollee has been asked to pay the correct amount based on the 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 copayment for an inpatient stay provided from May 14, 2021, through May 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Handicare electric patient lift that is installed into the ceiling (E1399).

You asked the Plan to pre-approve the custom ceiling lift. You say that you require this specific type of lift. The Plan denied your request. The Plan says it will cover a standard lift from a network provider, but not the home modifications and changes necessitated by the installation of a lift system such as this.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. A standard lift is considered necessary for you, but the additional components of this lift exceed necessity requirements and no longer serves 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 a Handicare electric patient lift that is installed into the ceiling (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on January 25, 2021.

You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says hearing aids ordered through providers not contracted with the Plan's hearing provider are not covered.

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 ordered though the Plan's hearing provider. 

We looked at the file and the Plan's rules. The file shows that the hearing aids were not ordered through the Plan's hearing provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on January 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics, shoe lifts (E1399).

You asked the Plan to pre-approve foot orthotics. You say that you have been using a shoe lift because you have limited mobility issues. Your legs are not the same length, one is shorter than the other and you are using a walker. You need a shoe lift in your left shoe order to walk. The Plan denied your request. The Plan says the lift is not being used to treat a diabetic condition therefore, the enrollee does not meet the Medicare criteria for therapeutic shoes, heel lifts.

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, shoe lifts (E1399).
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 monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria is not met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and 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 assesses 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 use insulin with at least three daily injections or require 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D5213, D5214).

You asked the Plan to pre-approve the services. You say that you have blisters on your tongue because of missing teeth. The Plan denied your request. The Plan says this is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental services (D5213, D5214).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Sandostatin LAR.
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 that the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the use of Sandostatin LAR is supported by the Medicare-approved drug compendia as an off-label treatment of short bowel (gut) syndrome. The records support that the medication is safe and effective and reasonable and medically necessary for the enrollee at this time. 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 been met. Therefore, we decided that the Plan has to pre-approve Sandostatin LAR.
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 lette
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on June 8, 2021 by a Medicare opt out provider.

You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you would like to know why this same claim was paid 6 months ago. The Plan denied your request. The Plan says these services were rendered by a provider who chose not to receive Medicare funds. The Plan also says that the treating provider opted out of Medicare effective August 1, 2009, to August 23, 2023.

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 covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on June 8, 2021 by a Medicare opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home-delivered meals.
You asked the Plan to pre-approve home-delivered meals. You say that the request should have been made
following discharge from the hospital. The Plan denied your request. The Plan says that the Plan will not preauthorize
post discharge meal services for the member. The member was not admitted with the qualifying
diagnosis of congestive heart failure for coverage of the meal plan supplemental benefit.
The Plan contract offers a supplemental Home-delivered meals benefit. The benefit covers meals delivered to
your home following discharge from a hospital due to congestive heart failure.
We looked at the file and the Plan's rules. The file shows that you do not have the qualifying diagnosis of
congestive heart failure for coverage of the meal plan supplemental benefit. Based on this information, we
decided that Plan's rules for coverage of home-delivered meals have not been met. Therefore, we decided that
the Plan does not have to pre-approve home-delivered meals.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a personal emergency response system (PERS).

You asked the Plan to pre-approve the PERS. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria for this PERS have not been met.

The Plan must follow Medicare rules. Medicare rules say that PERS is not covered by Medicare as it is not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a personal emergency response system (PERS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve low vision aids for the enrollee.

You asked the Plan to pre-approve the services. You say that this is not medically necessary. The Plan denied your request. The Plan says low vision aids are not covered.

The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear.

The services you asked the Plan to pre-approve are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pre-approve low vision aids for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.

You asked the Plan to pre-approve home health services. You say that you need a home health nurse to come to your house acquire blood and urine samples from time to time. You also say that you refuse to take public transportation and are unable to drive for health reasons. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Specifically, the file does not indicate that you are homebound. Additionally, the file does not include a physician order for the requested services. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitoring system.

You asked the Plan to pre-approve a Freestyle Libre. You say that the requested system is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for continuous glucose monitors 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 the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitoring system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prosthetic Leg with Computerized Knee and Additional Parts.

You asked the Plan to pre-approve the K3 microprocecssor knee. You say that the computerized knee is necessary. The Plan denied your request. The Plan says the documentation does not show why a computerized knee is required over a K3 mechanical knee.

The Plan must follow Medicare rules. Medicare rules say that coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of knee. This information needs to be in the documentation, and it is not. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the K3 microprocecssor knee have not been met. Therefore, we decided that the Plan does not have to pre-approve Prosthetic Leg with Computerized Knee and Additional Parts.
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 the IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met at a different level of care. 
 
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 based on the medical records provided the complexity of the enrollee's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an 
IRF 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain pontic (D6241) and porcelain crowns (D6751).

You asked the Plan to pre-approve a porcelain pontic and porcelain crowns. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested services are not a covered benefit under the 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 services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a porcelain pontic (D6241) and porcelain crowns (D6751).