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

We decided that the Plan has to pre-approve bioimpedance spectroscopy 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 that a review of the current medical literature indicates that this service is considered experimental and investigational.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the Centers for Medicare and Medicaid Services (CMS) has recognized this technique in the evaluation and follow-up for breast cancer-related lymphedema. The enrollee had a prior exam on 3/1/21 with right arm impedance score of -7.7 and the follow-up has been requested to assess treatment effectiveness and prognosis. While the technique is reasonably new, the utility in this patient group has been established. This imaging should be approved for these reasons. 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 services have been met. Therefore, we decided that the Plan has to pre-approve bioimpedance spectroscopy 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the services you require are called custodial 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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for SNF services.

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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
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 you are no longer on insulin.
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services from an out-of-network (OON) provider.
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 available from network providers.
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 home health services from an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a LifeAlert system.
You asked the Plan to pre-approve these services. You say that you have cardiac issues. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that items that do not contribute meaningfully to the treatment of an illness or injury or the functioning of a malformed body member are not covered. The item at appeal is a medical life alert system. While this item may be of benefit to you, it is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a LifeAlert system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) receiver (K0554) and supplies (K0553).
You asked the Plan to pre-approve a CGM receiver and supplies. You say that the items are medically necessary. The Plan denied your request. The Plan says the enrollee is treated with daily injections of insulin twice daily, not the required three times daily.
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 CGM receiver and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) receiver (K0554) and supplies (K0553).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided April 22, 2021.
You asked the Plan to pay for the periodontal maintenance. You say that you would like the service processed as your routine dental cleaning. The Plan denied your request. The Plan says this service is not covered under your 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 pay for the periodontal maintenance (D4910) provided April 22, 2021
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz.
You asked the Plan to pre-approve Supartz. You say that Supartz will help the enrollee decrease their pain. The
Plan denied your request. The Plan says the enrollee has not tried all of the Plan's preferred medicines,
Durolane, Gelsyn-3, and Synvisc/Synvisc-One.
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 Supartz. Our physician reviewer found
that the enrollee has osteoarthritis of the knee. The requested medication is a new start. The Plan requires a trial
of Durolane, Gelsyn-3, and Synvisc/Synvisc-One before they will approve the requested drug. The provided
records do not indicate that the enrollee has tried and failed the plan's preferred drugs. The record does not
indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred
drugs. Therefore, the requested drug is not medically reasonable or necessary 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 Supartz have not been met. Therefore, we decided that the Plan does not have to
pre-approve Supartz.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Radiologic examination represented by code 71045 provided on May 13, 2021.

You asked the Plan to pay for code 71045. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

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, we have confirmed that code 71045 has a bundled relationship with code 32555 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the Radiologic examination represented by code 71045 provided on May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve porcelain crowns (D2740), and core build up (D2950) for teeth # 21 and 30.

You asked the Plan to pre-approve the dental services. You say that the crowns are medically necessary. The Plan denied your request. The Plan says porcelain crowns are not listed as covered services. The Plan also says that core build up are not listed as covered services either.

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 porcelain crowns and core build up are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve porcelain crowns (D2740), and core build up (D2950) for teeth # 21 and 30.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6533.

You asked the Plan to pre-approve the compression stockings. You say that your feet are swollen. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are non-covered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 skilled nursing home health visits (G0299) to be
provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the skilled nursing visits. You say that you need the services to be able to
clean and care for yourself. The Plan denied your request. The Plan says enrollee's must receive their medical
services from an in-network provider with the exception being urgent or emergent services. Non-emergent
services with non-contracted providers require prior authorization before services being rendered.

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
10 skilled nursing home health visits (G0299) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May 20, 2021.
You asked the Plan to pay for the dental service. You say that you should not owe the $30 copayment. You say that you used an in network provider. You say that the in network provider should have known that this would not be covered by your insurance. You also say that no one told you, you have a new policy plan. The Plan denied your request. The Plan says coverage for a comprehensive oral evaluation is limited to once every 36 months. The Plan also says that the frequency limit has 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 and comprehensive oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on March 26, 2019. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Lumex lightest foam/gel overlay.

You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your request. The Plan says this product is not covered by Medicare and has not been issued a Healthcare Common Procedure Coding System (HCPCS) code.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

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 item. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not indicate that this item serves a purely medical need, or that your condition requires this item for treatment.

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 item have not been met. Therefore, we decided that the Plan does not have to pre-approve a Lumex lightest foam/gel overlay.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says he requested admission to a LTACH does not meet criteria.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that the enrollee requires that are not available at the 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower
denture (D5214).
You asked the Plan to pre-approve the dental services. You say that the dentures you have right now are
broken. You say that the bottom denture is cracked. You say that it was repaired but do not fit properly
anymore. You also say that one of the top teeth is cracked and was pulled. The Plan denied your request. The
Plan says dentures are covered once every 60 months. The Plan also says that the frequency limit has been
reached.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental
services when the services are medically necessary and reasonable.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of the dental services have not been met. Specifically, the frequency limit has been reached.
The record shows that the Plan paid for a partial upper denture that you received on August 18, 2018, and a
partial lower denture that you received on August 30, 2018. Therefore, we decided that the Plan does not have
to pre-approve a partial upper denture (D5213) and a partial lower denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the orthopedic office visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the office visit. You say that you are being forced to go to the emergency room at lease once a week for pain medication for your severe knee pain. You have been in a wheelchair ever since your initial surgery on January 2, 2021 The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 the orthopedic office visit 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 compression stockings identified with code A6549.

You asked the Plan to pre-approve the compression stockings. You say that you need these stockings. The Plan denied your request. The Plan says these are not covered.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
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 your doctors told you that you meet the criteria for an IRF admission. The Plan denied your request. The Plan says your records show that it is not reasonable to expect that you will be able to fully benefit from the intensity of services of an IRF.
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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
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. There is not a reasonable expectation that you 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.