Persius/hicric huggingface dataset:
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 SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you no longer require daily skilled services and the continuation of SNF is not medically necessary.  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 continued 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 continued skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
You asked the Plan to pre-approve dentures. You say that the enrollee's dentures were thrown away while they were in the hospital. You also say that the enrollee needs new dentures. The Plan denied your request. The Plan says dentures are covered once every 5 plan years. 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. Though the Plan offers a dental benefit in excess of Medicare coverage and complete dentures are listed as covered, the frequency limit has been reached. The record shows that the Plan paid for a complete upper and lower denture that the enrollee received on August 8, 2019, less than 5 years ago. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.  You asked the Plan to pre-approve continued SNF care. You say that the requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued SNF 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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. This enrollee does require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment. Based on the medical records provided daily skilled services are not required. This enrollee does not require the services on an inpatient basis, only in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor and related
supplies.
You asked the Plan to pre-approve a Dexcom device and related supplies. You say that your provider wants
you to have the requested device to better track blood sugar. The Plan denied your request. The Plan says rules
for coverage for the requested brand of durable medical equipment have not been met.
The Plan must follow Medicare rules. Medicare rules say that MA Plans may specify brands and manufacturers
as preferred and charge lower cost-sharing for the preferred brands or may limit DME to only those preferred
brands and manufacturers.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a Dexcom device and related supplies have not been met. Specifically, the case record does not
support the medical necessity of the requested item. Therefore, we decided that the Plan does not have to preapprove
a Dexcom continuous glucose monitor and related supplies.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for lodging and transportation costs from May 11, 2021, to July 10, 2021.
You asked the Plan to pay for the costs. You say that you had to stay in Tucson for the transplant follow-up
appointments, testing, and evaluation. The Plan denied your request. The Plan says that according to the
transplant team, the enrollee information is not listed on the receipts for reimbursement.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The plan has not substantiated their denial in this case. The plan contract clearly
states that the denied transportation and lodging costs are covered in this case. You submitted receipts for
reimbursement, and they should be covered by the plan per your contract. The plan contract does not specify
how reimbursement should be presented by enrollees. Therefore, we decided that the Plan has to pay for
lodging and transportation costs from May 11, 2021, to July 10, 2021.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for th domiciliary visit provided on July 30, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary visit. You say that the provider relies on facility staff to verify eligibility and obtain the proper authorization. You say the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the domiciliary visit provided on July 30, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services.
You asked the Plan to pre-approve the skilled nursing facility services. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 the skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has made slow progress with therapy. There is no indication that transfer to a skilled nursing facility is required. The enrollee can continue to received skilled services at the current inpatient facility or be stepped down to a lower level of care when appropriate. There are no services offered at a SNF that are not offered at an inpatient rehab 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 skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve SPECT nuclear medicine localization of tumor with concurrently acquired CT transmission scan.  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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has dyspnea on exertion considered to be anginal equivalent. The records indicate that a myocardial perfusion Lexiscan was planned. The records do not support medical necessity of the requested service. The SPECT nuclear medicine localization with concurrent CT is not recommended.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve SPECT nuclear medicine localization of tumor with concurrently acquired CT transmission scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 1 power scooter.
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your
request. The Plan says there should be a durable medical equipment (DME) revaluation and then a resubmission
of the request.
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.
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 scooter. Our reviewer says that the
requested scooter is not medically reasonable or necessary. Our physician reviewer found there is no
documentation that you have a mobility deficit that impairs participation in mobility related activities of daily
living such as toileting, feeding, grooming and bathing in customary locations within the home. The provided
records report the scooter is being requested for shopping and mobility in the community.
There is no documentation that the deficit could not be helped by the use of walker, cane, or manual
wheelchair. There is no documentation that you could safely operate the scooter.
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 scooter have not been met. Therefore, we decided that the Plan does not
have to pre-approve a group 1 power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for an office visit and synvisc injection (J7325) provided on September 21, 2021.
You asked the Plan to waive the cost-sharing for the office visit and synvisc injection. You say that the services should be covered as you were not made aware of the copayments beforehand. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.
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 $10 copayment for Physician/Practitioner services, including doctor's office visits and a 20% coinsurance for Medicare Part B prescription drugs.
You have been asked to pay a $10 copayment for an office visit and a 20% coinsurance for a synvisc injection (the allowed amount is $1,045.44 x 20% = $209.09). Synvisc injections fall within the Medicare Part B prescription drugs 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 cost-sharing for an office visit and synvisc injection (J7325) provided on September 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #4 and a core buildup,
including any pins when required (D2950) for tooth #4.
You asked the Plan to pre-approve the crown and core buildup. You say that you experienced poor service with
the previous provider and did not file an appeal because the provider compensated you. You also say that you
would like to retain your teeth and would like these services to be approved due to the poor service that was
previously provided. The Plan denied your request. The Plan says these services exceed the maximum counts
allowed per period.
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, crown (D2740) and core buildup,
including any pins when required (D2950) are each limited to one procedure per tooth every five plan years.
The record shows that you received a crown (D2740) on tooth #4 and a core buildup, including any pins when
required (D2950) on tooth #4 on January 11, 2018, and your crown (D2740) and core buildup, including any
pins when required (D2950) benefits for tooth #4 have been exhausted. Therefore, we decided that the Plan
does not have to pre-approve a crown (D2740) for tooth #4 and a core buildup, including any pins when
required (D2950) for tooth #4.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor and related supplies.
You asked the Plan to pre-approve a continuous glucose monitor and related supplies. You say that you need to be more in control of your blood sugar numbers and that the requested continuous glucose monitor will help with that. 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 you do 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 and related supplies
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided September 15, 2021.
You asked the Plan to pay for the comprehensive oral exam. You say that you switched to an in-network dentist and do not feel the denial was fair. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.
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 comprehensive oral exam once every three plan years. We looked at the file and Medicare rules. A comprehensive oral exam was previously covered on March 3, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided September 15, 2021
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency room visit provided on July 28, 2021.  You asked the Plan to waive the copayment for the emergency room visit. You say that the services should be covered as everyone in the waiting room was mask less and you ended up leaving before being seen. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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.        You have been asked to pay a $90 copayment for the emergency room visit. the emergency room visit falls within the Emergency care benefit category. The record includes medical records indicating that you were seen by a provider and then discharged. 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 July 28, 2021.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission.
Our physician reviewer found 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 a past medical history of diabetes, seizures, recent orbital fracture after a fall, and traumatic brain
injury in 2018 who is living at home with frequent falls. 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, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or
occupational therapy, there is no documentation of a need for an intensive rehabilitation program.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
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 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain
and lumbar spinal stenosis with claudication. The record indicates that the enrollee has severe foraminal
stenosis and is undergoing laminectomy. The documentation does not support that the Superion spacer is
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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Vertiflex Superion spacer.