Persius/hicric huggingface dataset:
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 admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  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 based on the documentation provided you appear to not be stable enough for transfer at this time. Acute care services can be safely administered at the current facility for the time being until treatment is completed and transfer to a lower level of care is more appropriate. You do not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that you require that are not already available and covered at the current facility.   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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for occupational therapy.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says there is an available provider for occupational therapy in the enrollee's network.
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
an out-of-network referral for occupational therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of a new patient (99324), the trimming of a skin lesion (11055), and the nail debridement (11721) rendered by the out-of-network (OON) provider on August 5, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.  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 the domiciliary or rest home visit for the evaluation and management of a new patient (99324), the trimming of a skin lesion (11055), and the nail debridement (11721) rendered by the out-of-network (OON) provider on August 5, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound provided on September 24, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says an
appropriate modifier was not 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.
The file shows that CPT code 76770 was billed with 93976. We looked at the file and the rules. We find that
CPT code 76770 may be eligible for payment when billed with this code pair. The claim information does not
show that the code at issue was billed with a modifier suitable for payment. Based on this information, we
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided
that the Plan does not have to pay for the abdominal ultrasound provided on September 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis tablet 5mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says self-administered drugs do not fall under Part B coverage.
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 Eliquis tablet 5mg for the
enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Injectafer for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no record of a trial of the preferred drugs.
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 the drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found there is no
documentation of a trial and failure of the preferred drugs, or that these drugs would likely be less effective
and/or have adverse effects 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 the drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Injectafer for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for intermittent limb compression device.  You asked the Plan to pay for intermittent limb compression device. You say that the item is medically necessary. The Plan denied your request. The Plan says the member does not have lymphedema or chronic venous insufficiency with venous stasis ulcers.  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 intermittent limb compression device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.

You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.

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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested procedure is experimental. More research is needed. 

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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implantable sacral nerve stimulator.
You asked the Plan to pre-approve an implantable sacral nerve stimulator. You say that this service is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of the implantable sacral nerve stimulator.
The Plan must follow Medicare rules. The rules state that for Medicare to cover an implantable sacral nerve stimulator, there must be a sacral nerve stimulator trial first. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an implantable sacral nerve stimulator have not been met. Specifically, the record does not show that a sacral nerve stimulator trial was tried first. Therefore, we decided that the Plan does not have to pre-approve an implantable sacral nerve stimulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), cone beam computed tomography (CT) capture (D0383), surgical extraction (D7210), bone replacement graft for ridge preservation (D7953), surgical placement of implant body: endosteal implant (D6010), guided tissue regeneration (D4266), and sinus augmentation (D7951) provided from June 30, 2020, to August 27, 2020 by an out-of-network (OON) provider.

You asked the Plan to pre-approve the dental services. You say that you were not aware that the Plan had changed dental carriers in 2020 and 2021. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that you did not have any OON benefits on your plan in 2020.

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 OON. Therefore, we decided that the Plan does not have to pre-approve the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), cone beam computed tomography (CT) capture (D0383), surgical extraction (D7210), bone replacement graft for ridge preservation (D7953), surgical placement of implant body: endosteal implant (D6010), guided tissue regeneration (D4266), and sinus augmentation (D7951) provided from June 30, 2020, to August 27, 2020 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for continued dialysis.

You asked the Plan to pre-approve the referral. You say that you have been at this provider for five years. The Plan denied your request. The Plan says there are in-network providers available.

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 an out-of-network referral for continued dialysis.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (81479) rendered by the out-of-
network (OON) provider on April 19, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the laboratory service (81479) rendered by the out-of-network (OON) provider on
April 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a power scooter purchased on May 26, 2021.  You asked the Plan to pay for a power scooter. You say that this should be covered. The Plan denied your request. The Plan says this was not purchased from a supplier that participates in Medicare.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a power scooter purchased on May 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids.
You asked the Plan to pre-approve hearing aids. You say that you need the hearing aid for your left ear. You
say that you do not have the financial means to purchase the hearing aid, nor can you wait 14 months for the
benefit to be available again. The Plan denied your request. The Plan says your hearing aid benefit is
exhausted.
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 every two years.
We looked at the file and the Plan's rules. The file shows that you received a hearing aid on October 4, 2021,
and your hearing aid benefit was exhausted. You will be eligible for new hearing aid benefit on
January 1, 2023. 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 pre-approve hearing aids.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided on
October 9, 2021.
You asked the Plan to waive the copayment for an emergency room visit. You say that you should not have to
pay the copayment because you did not see a doctor after the initial vitals, and you left. The Plan denied your
request. The Plan says the proper copayment was applied.
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 $90
copayment for Emergency care per visit.
You have been asked to pay a $90 copayment for an emergency room visit. An emergency room visit falls
within the Emergency care benefit category. This means that you have been asked to pay the correct amount
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an
emergency room visit provided on October 9, 2021.
Your complaint about your experience with this provider is not a valid appeal for medical coverage. This part
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a
decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for outpatient surgery services provided on September 28 to September 29, 2021.  

You asked the Plan to waive the coinsurance for outpatient surgery services. You say that the services at issue clearly should be covered as they were medically necessary. The Plan denied your request. The Plan says the correct coinsurance was applied.     

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 20% coinsurance for outpatient surgery. Your contract also says that, unless the provider writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost-sharing amounts for outpatient surgery.  

You have been asked to pay $2,201.60, or less than 20% of the Medicare-allowed charge of $11,021.39, for outpatient surgery services. Outpatient surgery services fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that you have been asked to pay less than or equal to the full and 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 coinsurance for outpatient surgery services provided on September 28 to September 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on October 19, 2021.
You asked the Plan to pay for the prophylaxis. You say that you were required to have another cleaning due to
an existing periodontal issue. You also say that it was agreed to be paid in 2020, but you do not know why it is
not approved in 2021. The Plan denied your request. The Plan says this procedure exceeds the frequency
limitations under your 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, prophylaxes are covered twice per
year. The record shows that you received prophylaxes (D1110) on March 10, 2021, and June 14, 2021 and your
prophylaxis (D1110) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for
the prophylaxis (D1110) provided on October 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Colchicine.
You asked the Plan to pre-approve Colchicine. You say that the enrollee is doing well on the medication. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Colchicine.
Benefits for Colchicine 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rhopressa for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. 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 Rhopressa 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 pre-approve a Millenial Medical In-Motion Folding Pro Underarm
Crutch (E0117).
You asked the Plan to pre-approve the crutch. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no medical reason for this brand-specific request.
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 crutch. Our reviewer says that the
requested crutch is not considered medically reasonable and necessary in this case. Our physician reviewer
found the documentation does not reveal objective findings on a physical exam that indicate you are unable to
use a non-brand specific standard crutch. The request exceeds your medical needs.
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 crutch have not been met. Therefore, we decided that the Plan does not have
to pre-approve a Millenial Medical In-Motion Folding Pro Underarm Crutch (E0117).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says there appears to be some concern that the devices are not as effective as surgical
decompression and lead to higher rates of reoperation.
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 device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that this device is experimental. More research is needed.
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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex device for the enrollee.