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

 We decided that the Plan does not have to pre-approve a sleep study to be provided by the requested out-of-network provider.  You asked the Plan to pre-approve the sleep study. The Plan denied your request. The Plan says the referring doctor and the sleep facility are both out-of-network with the enrollee's health Plan. The enrollee's health Plan only covers out-of-network or non-contracted services if they are not available within the network or if it is an emergency. The medical notes indicate that this is not an emergency.  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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a sleep study to be provided by the requested out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide coverage for additional routine transportation trips.  You asked the Plan to provide coverage for additional routine transportation trips. You say that you need more trips to get to all of your doctor's appointment as you have no money or car. The Plan denied your request. The Plan says the requested service is covered under the member's Plan, but the requested amount exceeds the limit listed by the Plan.  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   We looked at your request, the records in the case file, and the rules. The file shows that the Plan covers a maximum of 48 one-way trips per calendar year. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the 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 need to see an expert in this field to diagnose your condition. The Plan denied your request. The Plan says the provider is out-of-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 the office visit 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 pre-approve two periodic oral evaluations (D0120 x2) and two prophylaxes (D1110 x2) to be rendered by an out-of-network (OON) provider.

You asked the Plan to pre-approve the periodic oral evaluations and prophylaxes. You say that you would like to continue care with this provider. You also say that you were incorrectly advised that this provider was in-network. The Plan denied your request. The Plan says the medically necessary services are available in the service area with participating providers.

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 periodic oral evaluations (D0120 x2) and two prophylaxes (D1110 x2) to be rendered by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis.

You asked the Plan to pre-approve Eliquis. The Plan denied your request. The Plan says the drug is not covered 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 Eliquis.

Benefits for Eliquis 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 Tempur-Pedic Proadapt Firm Mattress with Temper Ego Smart Base.  You asked the Plan to pre-approve these services. You say that you have sleep apnea and lumbar spinal stenosis and would benefit from the bed. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a Tempur-Pedic Proadapt Firm Mattress with Temper Ego Smart Base.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve endovenous radiofrequency ablation and sclerotherapy.  You asked the Plan to pre-approve endovenous radiofrequency ablation and sclerotherapy. You say that this is medically necessary. The Plan denied your request. The Plan says the submitted records do not show that the requirements for coverage have been met.  The Plan must follow Medicare rules. Medicare rules say that  invasive procedures for the treatment of varicose veins are considered medically reasonable and necessary when there has been an evaluation of the patient has been performed including a history and physical examination, the CEAP clinical classification and the revised Venous Clinical Severity Score (VCSS), a duplex scan of the deep and superficial venous systems supports the examination findings, and a duplex scan confirms the presence of reversed venous flow (reflux) with provocative maneuvers in the saphenous, or perforator veins is 500 milliseconds or greater and absence of deep venous obstruction.  We looked at the file and Medicare rules. The submitted records do not document an evaluation of the enrollee or that duplex scans have been performed. Based on this information, we decided that Medicare rules for coverage of endovenous radiofrequency ablation and sclerotherapy have not been met. Therefore, we decided that the Plan does not have to pre-approve endovenous radiofrequency ablation and sclerotherapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the wheelchair repair to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the wheelchair repair. You say that the wheelchair was purchased from this company, and you would like to stay with this provider. The Plan denied your request. The Plan says the provider is out-of-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 the wheelchair repair 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 a Purewick catheter system.  You asked the Plan to pre-approve these services. You say that you need the item to manage your condition. The Plan denied your request. The Plan says the services are not covered.  The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable.   While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve a Purewick catheter system.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an office visit and evaluation from an out-of-network provider.  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 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 office visit and evaluation from an out-of-network provider.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve computed tomography (CT) scan of the thoracic and cervical spine for the enrollee.  You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no record of any conservative treatment from the past three months.  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 the scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found the enrollee has a red flag that is a cause of concern. This is the lower extremity weakness, and intermittent bowel and bladder incontinence, especially with the prior history of discitis at the T10-11 level. The requested CT myelogram is reasonable due to the extensive spinal hardware she has from prior surgeries. The concern here would be recurrent infection and the requested total spine CT myelogram is reasonable even without a six week course of physical therapy.  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 scan have been met. Therefore, we decided that the Plan has to pre-approve computed tomography (CT) scan of the thoracic and cervical spine 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a periodic oral evaluation (D0120) and prophylaxis (D1110) to be rendered by an out-of-network (OON) provider.

You asked the Plan to pre-approve the periodic oral evaluation and prophylaxis. You say that you get nervous when you go to the dentist but are comfortable with the dentist you are requesting to see. You also say that you are already an established patient with this provider and feel that it is your right to continue seeing someone you are comfortable with. The Plan denied your request. The Plan says these services to be rendered OON are not medically necessary. The Plan also says that these services are available in the service area with participating providers.

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 a periodic oral evaluation (D0120) and prophylaxis (D1110) to be rendered by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) capture and interpretation (D0365), three surgical placements of implant bodies: endosteal implants (D6010 x3), two implant supported porcelain/ceramic crowns (D6065 x2), two radiographic/surgical implant indexes (D6190 x2), and a bone replacement graft for ridge preservation (D7953).

You asked the Plan to pre-approve the cone beam CT capture and interpretation, endosteal implants, implant supported porcelain/ceramic crowns, radiographic/surgical implant indexes, and bone replacement graft. You say that you need these implants. The Plan denied your request. The Plan says these services are 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 cone beam computed tomography (CT) capture and interpretation (D0365), three surgical placements of implant bodies: endosteal implants (D6010 x3), two implant supported porcelain/ceramic crowns (D6065 x2), two radiographic/surgical implant indexes (D6190 x2), and a bone replacement graft for ridge preservation (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve five prefabricated abutments (D6056 x5) and five abutment supported porcelain/ceramic crowns (D6058 x5).  You asked the Plan to pre-approve the prefabricated abutments and abutment supported porcelain/ceramic crowns. You say that you would like these services to be reconsidered. You also say that the enrollee already had implants placed in the areas being requested. The Plan denied your request. The Plan says these services are not covered under the enrollee's 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 five prefabricated abutments (D6056 x5) and five abutment supported porcelain/ceramic crowns (D6058 x5).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.

You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your request. The Plan says your benefit only allows 12 trips.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at your request, the records in the case file, and the rules. The file shows that the Plan covers a maximus of 12 routine transportation trips per year. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a manual wheelchair.  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 covered.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.   Records show that these services is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the CT scan. You say that the enrollee lost 20 pounds in the last year and the previous CT scan showed a dilated pancreatic duct. The Plan denied your request. The Plan says the provider is out-of-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 the CT scan to be provided by an out-of-network (OON) provider.
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 you would like reconsideration because the requested IRF care is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for the requested IRF care.

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 you do not require the intensity of services provided at an IRF.

Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care. 

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 a pneumatic compression device (E0651) and accessory (E0667).  You asked the Plan to pre-approve a pneumatic compression device and accessory. You say that you need this. The Plan denied your request. The Plan says the requirements for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device (PCD) coded as E0650 or E0651 is covered for both primary and secondary lymphedema in beneficiaries with chronic and severe lymphedema when the beneficiary has persistence of chronic and severe lymphedema as identified by the documented presence of marked hyperkeratosis with hyperplasia and hyperpigmentation, papillomatosis cutis lymphostatica, deformity of elephantiasis, skin breakdown with persisting lymphorrhea, and/or detailed measurements over time confirming the persistence of the lymphedema with a history evidencing a likely etiology. In addition to this documented persistence, the lymphedema is then documented to be unresponsive to other clinical treatment over the course of a required four-week trial. If the base PCD is not covered, related accessories are not eligible for reimbursement.  We looked at the file and Medicare rules. The records do not show that you have chronic and severe lymphedema as identified by the documented presence of the symptoms described above or that you failed four weeks of conservative therapy. Based on this information, we decided that Medicare rules for coverage of a pneumatic compression device and accessory have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0651) and accessory (E0667).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.  You asked the Plan to pre-approve physical therapy services to be provided by the requested out-of-network provider. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the Plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the Plan.  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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.