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

 We decided that the Plan does not have to pre-approve additional routine transportation mileage.  You asked the Plan to pre-approve routine transportation. You say that you need to see a doctor at this location. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because routine transportation beyond 50 miles per one-way trip is not covered by the Plan.  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 each one-way trip does not exceed 50 miles of driving distance.   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 because the destination you have requested is more than 50 miles of driving distance per one-way trip. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation mileage.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the adjacent tissue transfer or rearrangement (14000) provided July 23, 2021.  You asked the Plan to pay for the adjacent tissue transfer or rearrangement. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the requested procedure code would be considered inclusive to procedure code 19301.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 14000 is adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less.  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the adjacent tissue transfer or rearrangement. Our reviewer says that CPT code 14000 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided has documented that CPT code 19301 - Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy) was performed on July 23, 2021.  CPT 14000 is inclusive to CPT 19301 because simple, intermediate, and complex layered closure is included in the work represented by code 19301.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the adjacent tissue transfer or rearrangement have not been met. Therefore, we decided that the Plan does not have to pay for the adjacent tissue transfer or rearrangement (14000) provided July 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power wheelchair.  You asked the Plan to pre-approve a power wheelchair. You say that the requested power wheelchair is a medical necessity for you. The Plan denied your request. The Plan says rules for power mobility devices have not been met.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   The file does not show that you can safely operate the PMD being requested. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a transthoracic echocardiography (93307).  You asked the Plan to pre-approve a transthoracic echocardiography. The Plan denied your request. The Plan says review of the information shows that an ultrasound of the heart is being requested. However, from the information provided, it is being requested because the enrollee has a family history of heart failure. However, the enrollee is not having any signs or symptoms that suggest the enrollee has heart failure or a heart problem.   The Plan follows Medicare rules. Medicare rules say that the use of the ultrasound technique is sufficiently developed that it can be considered essential to good patient care in diagnosing a wide variety of 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 transthoracic echocardiography. Our reviewer says that a transthoracic echocardiography is not medically necessary. Our physician reviewer found that based on the medical records provided there is no documentation that the requested transthoracic echocardiography in this case meets the Medicare coverage criteria. The records document a family history of heart failure, but the records do not document that this enrollee is displaying any signs or symptoms of heart disease.   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 transthoracic echocardiography have not been met. Therefore, we decided that the Plan does not have to pre-approve a transthoracic echocardiography (93307).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554) and related supplies (K0553).  You asked the Plan to pre-approve a continuous glucose monitor and related supplies. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage 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 continuous glucose monitor and related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554) and related supplies (K0553).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a complete upper denture (D5110), a complete lower denture (D5120), and 4 extractions (D7140).  You asked the Plan to pre-approve the dental services. You say that your handbook states that the services are covered. The Plan denied your request. The Plan says complete dentures are not listed as covered service. The Plan also says extractions are not listed as covered services.  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 complete dentures and extractions are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110), a complete lower denture (D5120), and 4 extractions (D7140).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia (J0897).  You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit since it is being dispensed by the pharmacy.  The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.  In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).   Benefits for Prolia 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 pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on May 11, 2021.  You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied your request. The Plan says the ambulance transport was not medically necessary.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   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 pay for ambulance service, basic life support, non-emergency transport. Our reviewer says that the ambulance transport was not medically necessary. Our physician reviewer found that the enrollee is an 88-year-old female who was evaluated in the hospital and was transported via ambulance to home. She was able to get out of bed on her own and sit in a wheelchair. Her vitals were stable. She received no treatment during transport.   The documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this enrollee. The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. The documentation does not support that the ambulance transport on May 11, 2021 was medically reasonable and necessary for the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on May 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitoring (K0553, K0554) provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve a therapeutic continuous glucose monitoring. You say that you were not informed that the provider was not in-network and that the Plan did not give you the correct information. The Plan denied your request. The Plan says your records received do not indicate that you have an emergent or urgent medical condition, or need specialized services that are not available in the network. The Plan also says that there are in-network providers within a reasonable distance from your location that can provide this services or item.  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 pre-approve a therapeutic continuous glucose monitoring (K0553, K0554) provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide coverage for twenty-two (22) additional routine transportation trips.  You asked the Plan to provide coverage for twenty-two (22) additional routine transportation trips. You say that you need additional transportation trips to get to medical appointments. The Plan denied your request. The Plan says you have exceeded your benefit limit.  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.  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. Therefore, we decided that the Plan does not have to provide coverage for twenty-two (22) additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compressor, segmental home model without calibrated gradient pressure (E0651) and a segmental pneumatic appliance for use with pneumatic compressor for the full leg (E0667) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve a pneumatic compressor, segmental home model without calibrated gradient pressure and a segmental pneumatic appliance for use with pneumatic compressor for the full leg. You say that your patient has severe bilateral lymphedema and diabetes mellitus type 2. You also say that the edema causes skin irritation and cracking that predisposes him to lower extremity infections which can be exacerbated by the diabetes and become severe. The Plan denied your request. The Plan says your request for an exception for out-of-network (OON) services does not meet the requirements for approval. The Plan also says that the records received did not show that the enrollee has an emergent or urgent medical condition, or are in need of a specialized service. The Plan also says that there are in-network providers that can provide this item directly to the enrollee's home.  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 pneumatic compressor, segmental home model without calibrated gradient pressure (E0651) and a segmental pneumatic appliance for use with pneumatic compressor for the full leg (E0667) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve adult diapers/briefs.  You asked the Plan to pre-approve incontinence supplies. You say that this is medically necessary due to hemorrhoids. The Plan denied your request. The Plan says these items fall outside of the scope of coverage.  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 adult diapers/briefs.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve four diabetes screenings per year.  You asked the Plan to pre-approve the services. You say that this is needed to monitor diabetes. The Plan denied your request. The Plan says screening for diabetes is not considered reasonable and medically necessary.  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. Diabetes screening tests are one of the exceptions. Plan rules state that two diabetes screenings are covered per year.  There are no medical records or clinical rationale provided for why four screenings are needed per year. Therefore, we decided that the Plan does not have to pre-approve four diabetes screenings per year.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve eyeglasses.  You asked the Plan to pre-approve eyeglasses. The Plan denied your request. The Plan says vision wear, such as new eyeglasses, is typically covered by your supplemental vision benefit, unless you have had eye surgery with a change in vision post operatively. Lenses are covered on a yearly basis, and it has not yet been one year since you have received glasses.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services every year.  We looked at the file and the Plan's rules. The file shows that the supplemental eyewear benefit is covered on a yearly basis, and it has not yet been one year since you have received eyewear.  Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pre-approve eyeglasses.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Injectafer (J1439).  You asked the Plan to pre-approve Injectafer. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy requirements have not been met.  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 Injectafer. Our reviewer says that the requirements for coverage of Injectafer have not been met. Our physician reviewer found the Plan requires a trial of Infed and Venofer before they will approve the requested drug. The records do not show that you have tried these drugs, that these drugs would not be effective, or that these drugs would have adverse effects for you.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have to pre-approve Injectafer (J1439).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve SNF services provided beginning November 12, 2021.  You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the Plan covered up to 100 days of SNF services in the benefit period and the benefit has been exhausted.  The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.   The file shows that the enrollee received 100 days of SNF care during the benefit period ending on  November 11, 2021. The Plan has covered 100 days of SNF care.   Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pre-approve SNF services provided beginning November 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve progressive lenses.  You asked the Plan to pre-approve progressive lenses. The Plan denied your request. The Plan says progressive lenses are not a covered vision benefit.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. Medicare says progressive lenses (V2781) will be denied as non-covered.   We looked at the file, the Medicare rules and the Plan's rules. Medicare says progressive lenses will be denied as non-covered. The Plan does not cover progressive lenses. Therefore, we decided that the Plan does not have to pre-approve progressive lenses.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve radiofrequency ablation 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 this is being requested too soon.  The Plan must follow Medicare rules. Medicare rules say that radiofrequency ablation is covered twice per year.  The records show that there were two previous radiofrequency ablations within a year of this request, in March 2021 and April 2021. 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 radiofrequency ablation for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a resin-based composite (D2391), prefabricated post and core in addition to crown (D2954), two crowns (D2740 x2), and a core buildup, including any pins when required (D2950).  You asked the Plan to pre-approve the resin-based composite, prefabricated post and core, crowns, and core buildup. You say that you did your part giving all of the necessary information to the dental office, but things were overlooked on their end which caused a delay in processing to have these services approved. The Plan denied your request. The Plan says the resin-based composite contains an invalid tooth surface. The Plan also says that x-rays to support your dental treatment were not received.  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. The x-ray that was submitted appears to be a faxed copy that was not clear and was not diagnostic. The record shows that the Plan made multiple attempts to obtain better x-rays, but none were provided. Therefore, we decided that the Plan does not have to pre-approve a resin-based composite (D2391), prefabricated post and core in addition to crown (D2954), two crowns (D2740 x2), and a core buildup, including any pins when required (D2950).