Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) scan of the abdomen (74175).

You asked the Plan to pre-approve a CTA scan. You say that the enrollee's symptoms are getting worse. The Plan denied your request. The Plan says the enrollee does not have signs and symptoms to support this is necessary.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a CTA scan. Our reviewer says that the requested CTA scan is not medically necessary. Our physician reviewer found the records do not support that member has severe abdominal pain, colitis, peritoneal signs, rectal bleeding, or unexplained leukocytosis to warrant concern for acute mesenteric or colonic ischemia. 

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 CTA scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) scan of the abdomen (74175).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cone beam CT capture and interpretation (D0364), extraction (D7210), bone replacement graft for ridge preservation (D7953), and surgical placement of implant body: endosteal implant (D6010).

You asked the Plan to pre-approve the cone beam CT capture and interpretation, extraction, bone replacement graft, and endosteal implant. You say that you had been on Prolia which may have contributed to the tooth weakness which caused the tooth to break and subsequently become infected. The Plan denied your request. The Plan says the requested procedures are dental services and are not covered by Medicare.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pre-approve 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 pre-approve a cone beam CT capture and interpretation (D0364), extraction (D7210), bone replacement graft for ridge preservation (D7953), and surgical placement of implant body: endosteal implant (D6010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transit system for the enrollee.

You asked the Plan to pre-approve a transit system. You say that this is necessary for the enrollee. The Plan
denied your request. The Plan says that this is not covered because it is for use outside the home.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate
and needed for use inside the home.

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not
have to pre-approve a transit system for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bicalutamide for the enrollee.

You asked the Plan to pre-approve this drug. You say that the enrollee needs this medication to treat his prostate cancer. 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 Bicalutamide 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermittent limb compression device (E0675) and pneumatic appliance (E0673) provided on July 8, 2020.

You asked the Plan to pay for an intermittent limb compression device and pneumatic appliance. You say that the requested items are a medical necessity for the enrollee for the prevention of deep vein thrombosis and pulmonary embolism. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for the prevention of deep vein thrombosis and pulmonary embolism.

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with venous stasis ulcers. 

The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous stasis ulcers.

Therefore, we decided that the Plan does not have to pay for an intermittent limb compression device (E0675) and pneumatic appliance (E0673) provided on July 8, 2020.
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 rehabilitation services are medically necessary. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services you are requesting do not meet the requirements for approval.

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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee has ongoing weakness. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the brand specific power operated vehicle.

You asked the Plan to pre-approve the brand specific power operated vehicle (E1230). You say that you need a
scooter because you have chronic hip and knee pain limiting your ability to walk. The Plan denied your
request. The Plan says there is no medical reason why a standard power scooter would not meet your needs.

The Plan follows Medicare rules. Medicare rules say that contract suppliers are not required to furnish a
specific brand name item or mode of delivery to a beneficiary unless prescribed by a physician or treating
practitioner to avoid an adverse medical outcome.

The Plan has approved you for a standard PMD. The home evaluation was done to show a standard PMD can
be used in your home. There is no documentation from your physician that the specific brand is medically
necessary. Therefore, we decided that the Plan does not have to pre-approve the brand specific power operated
vehicle.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal care services (T1012).

You asked the Plan to pre-approve the personal care services. The Plan denied your request. The Plan says
personal care services are not covered under your Medicare insurance.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from
trained medical or paramedical staff, is not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the personal care services have not been met. Specifically, we find that the services at issue in this
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve
personal care services (T1012).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), intraoral periapical radiographic images (D0220, D0230), and a bitewing radiographic image (D0270) provided on March 25, 2021.

You asked the Plan to pay for a limited oral evaluation, intraoral periapical radiographic images, and a bitewing radiographic image. You say that you were not aware that the provider changed to out-of-network. 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 a limited oral evaluation, intraoral periapical radiographic images, and a bitewing radiographic image 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 a limited oral evaluation (D0140), intraoral periapical radiographic images (D0220, D0230), and a bitewing radiographic image (D0270) provided on March 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections (64493 x 2, 64494 X 2), triamcinolone acetonide injections, 10 mg (steroid injection) (J3301 x 2), and dexamethasone sodium phosphate injections, 1 mg (steroid injection) (J1100 x 2).

You asked the Plan to pre-approve the injections. You say that you need these injections due to being in a car accident. You also say that you need these injections so you can move. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation does not include a physical examination that demonstrates the pain is axial/facet mediated. The reviewer found that the provided documentation does not include the level of the spine to be injected, whether the injections are intra-articular facet joint blocks or medial branch blocks, or if the injections are diagnostic or therapeutic. Therefore, the reviewer has determined that the requested injections are 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 the injections have not been met. Specifically, the file does not indicate where exactly the injections would be given. Therefore, we decided that the Plan does not have to pre-approve facet joint injections (64493 x 2, 64494 X 2), triamcinolone acetonide injections, 10 mg (steroid injection) (J3301 x 2), and dexamethasone sodium phosphate injections, 1 mg (steroid injection) (J1100 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6252).

You asked the Plan to pre-approve the pontic. You say that a bridge would be best for the space between the crown because an implant would not be the best. The Plan denied your request. The Plan says this service is not covered under your benefit package.

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 pontic (D6252).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says continuation of skilled services can be provided on an intermittent basis in an outpatient setting.

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.

Continued SNF services beyond September 3, 2021, were requested. 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 continued services. Our physician reviewer found that from a nursing perspective, you received oral medications and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, you were at a supervision to standby assist level with functional mobility. You required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy for tooth #'s 22 and 27.

You asked the Plan to pre-approve endodontic therapy. The Plan denied your request. The Plan says endodontics 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 endodontic therapy for tooth #'s 22 and 27.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission provided from March 14, 2021, to March 19, 2021.

You asked the Plan to waive the copayment for the inpatient hospital admission. You say that you cannot afford to pay this copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $370 copayment for each day for days 1 to 5 for in-network Medicare-covered hospital care and a $0 copayment for additional Medicare-covered days.

You have been asked to pay a $370 copayment for each day of the inpatient hospital admission. ($370 x 5 days = $1,850). The inpatient hospital admission falls within the "Inpatient Hospital Care" benefit category. The record shows you were an inpatient for 5 days. 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 the inpatient hospital admission provided from March 14, 2021, to March 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve carpal tunnel surgery (64721).

You asked the Plan to pre-approve carpal tunnel surgery. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says they do not have enough information to confirm that the enrollee has carpal tunnel syndrome.

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 carpal tunnel surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria for carpal tunnel surgery have not been met. The diagnosis is not clearly established in the records that the enrollee has been diagnosed with carpal tunnel 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 carpal tunnel surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve carpal tunnel surgery (64721).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two endodontic therapies (D3330 x2) and a surgical placement of implant body: endosteal implant (D6010).

You asked the Plan to pre-approve the endodontic therapies and endosteal implant. You say that the enrollee has pain to percussion and biting. 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 pre-approve two endodontic therapies (D3330 x2) and a surgical placement of implant body: endosteal implant (D6010).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation beyond the Plan's 48-
trip limit.

You asked the Plan to pre-approve additional routine transportation. You say that you would like additional
trips covered. The Plan denied your request. The Plan says at the time of the request the enrollee has used this
benefit by receiving a total of 47 one-way trips. Additional trips beyond the 48-trip limit are not covered.

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 a maximum of 48 trips per year.

We looked at your request, the records in the case file, and the rules. The Plan provided documentation
showing that you have used 47 of your routine transportation trips. Therefore, we decided that the Plan does
not have to pre-approve additional routine transportation beyond the Plan's 48-trip limit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and re-cement or re-bond crown (D2920) provided on May 10, 2021.

You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and re-cement or re-bond crown. You say that these services should be covered by the Plan in full. You also say that there was no way for you to know that these charges would be denied. The Plan denied your request. The Plan says benefits for these services have been satisfied and the frequency limitations have been exceeded.

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, periodic oral evaluation (D0120) and problem focused limited oral evaluation (D0140) share a frequency limitation of two procedure codes per calendar year. The Plan contract says that intraoral x-rays are limited to one procedure code per calendar year and that recementation is limited to one procedure code every five years. The record shows that you received a problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and re-cement or re-bond crown (D2920) on January 9, 2021, and you received a periodic oral evaluation on March 23, 2021 and your problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and re-cement or re-bond crown (D2920) benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and re-cement or re-bond crown (D2920) provided on May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) provided on May 5, 2021.

You asked the Plan to pay for the first intraoral periapical x-ray. You say that the x-ray was part of the evaluation. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) provided on May 5, 2021.