Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the knee orthosis (L1852) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the orthosis. You say that your knees are failing and you need the knee brace. 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 knee orthosis (L1852) 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 long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says there are no issues for which an LTACH may offer a therapeutic advantage.
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 physician reviewer found that in this case, the enrollee was admitted to the acute care hospital from an outside facility for pneumonia in setting of second degree burn injury and an incidentally found pulmonary cavitary lesion. The record indicates that the enrollee is improving and receiving necessary care. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prostatic arterial embolization (PAE) procedure.
You asked the Plan to pre-approve PAE procedure. You say that due to the enrollee's age and comorbidities he is not a good candidate for surgery, but he is a good candidate for PAE. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because studies have not proven that this service is helpful for the enrollee's condition.
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 PAE procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found prostatic arterial embolization (PAE) is considered experimental/investigational for treatment of benign prostate hyperplasia (BPH). Very limited studies have demonstrated possible short-term safety and efficacy. Guidelines do not recommend this procedure outside of a clinical trial 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 PAE procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve prostatic arterial embolization (PAE) procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upper partial denture (D5225).
You asked the Plan to pre-approve the upper partial denture (D5225). You say that you have been going to this
dentist for over a year and is in the middle of having work done. You say that you want to appeal the denial.
The Plan denied your request. The Plan says the service is not a covered benefit and dental services from outof-
network providers are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the
upper partial denture (D5225).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5211), retainer crowns (D6752) for teeth # 19 and 21, and a pontic (D6242) for tooth # 20.
You asked the Plan to pre-approve fixed bridge. You say that you are unable to chew food on the left side of your mouth. You also say that the partial denture is clearly needed. The Plan denied your request. The Plan says the requested three-unit posterior fixed bridge is beyond the scope of benefit coverage.
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 fixed bridge when the services are medically necessary and reasonable. 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 fixed bridge. Our reviewer says that the fixed bridge is not medically necessary. Our physician reviewer found a fixed bridge is considered for coverage only to replace a single upper, front tooth or two adjacent lower front teeth. Tooth # 20 is a back tooth. Therefore, the reviewer found that the requested fixed bridge does not meet the criteria for coverage. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of fixed bridge have not been met. Specifically, the file shows that the fixed bridge is being requested to replace a back tooth. Fixed bridges are only covered to replace front teeth. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5211), retainer crowns (D6752) for teeth # 19 and 21, and a pontic (D6242) for tooth # 20.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodic oral exam (D0120).
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial as you are in pain and need the work done immediately. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 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 periodic oral exam (D0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dental services coded as D9310, D7210, D9222, D9223, D9612 and D9230 to be provided by an out of network provider.

You asked the Plan to pre-approve the dental services. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says enrollee's must receive their dental services from an in-network provider.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

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 the dental services coded as D9310, D7210, D9222, D9223, D9612 and D9230 to be provided by an out of network provider.
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 it is not safe for you to go home without your strength back. The Plan denied your request. The Plan says your needs can be met with intermittent therapy in a custodial setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 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 physician reviewer found that you were admitted to an observation level of care due to a fractured rib after a fall. You have remained medically stable. You require moderate assistance for bed mobility. You are able to ambulate short distances with a walker and contact guard assistance. You do not require skilled nursing and/or skilled therapy services on a daily basis as an inpatient. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental extractions.
You asked the Plan to pre-approve dental extractions. The Plan denied your request. The Plan says this is not a
covered benefit.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve dental extractions.
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. The Plan denied your request. The Plan says you do not have skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient.
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 physician reviewer found that you were admitted to an acute hospital after a fall with multiple pre-syncopal episodes and a possible transient ischemic attack. The most recent therapy documentation indicates you are able to ambulate up to 140 feet with a walker. You are medically stable and does not have any daily complex daily wound care, parental medications or required care for a new or malfunctioning feeding tube. You do not require skilled nursing or therapy services on a daily basis as an inpatient. 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for air ambulance transport provided on June 3, 2021.
You asked the Plan to pay for air ambulance transport. You say that air ambulance transport was medically necessary. The Plan denied your request. The Plan says air ambulance transport was not medically necessary.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 pay for air ambulance transport. Our reviewer says
that air ambulance transport was not medically necessary. Our physician reviewer found that the enrollee is a 35-year-old female with a history of cerebral palsy who was admitted to a hospital in Naples Florida on
May 18, 2021 with stroke like symptoms. She was found to have a left-sided middle cerebral artery cerebrovascular accident (CVA), which resulted in right-sided hemiparesis and aphasia. During her hospitalization she developed abdominal pain and bladder spasm. A possible bladder mass was discovered. As of June 4, 2021 she was stable for discharge. She was transported by air ambulance to continue rehabilitation and continue urologic evaluation. The review has determined that the documentation did support that the enrollee suffered from an illness or injury that contraindicates transportation by any means other than ambulance. The documentation did not support that the enrollee's condition was such that the time needed to transport by ground, or the instability of transportation by ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's health. The documentation did not support that the transferring hospital did not have adequate facilities to provide the medical services needed by 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 air ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for air ambulance transport provided on June 3, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that your provider recommended rehabilitation because you are not able to bare weight for 6-8 weeks. You state the physical therapist said because you are able to get from your wheelchair to the bed you do not need to go to a facility. You state the rehabilitation center should be reconsidered because you are not able to move around or access anything in the home while you are bound to the wheelchair. The Plan denied your request. The Plan says the stay is not medically necessary based on the SNF criteria.
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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you no longer qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are functioning maximally given your current weight bearing status. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
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. The Plan denied your request. The Plan says the enrollee's
needs can be met at home or at an alternative level of 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 physician reviewer
found that the enrollee has a past medical history including end-stage renal disease requiring hemodialysis who
was admitted to an acute hospital with bleeding from an arteriovenous fistula. He was admitted at an
observational level of care with plans for a fistulogram. He has been treated and remains stable. He does not
require skilled nursing and/or skilled therapy services on a daily basis as an inpatient. Therefore, an admission
to a SNF for inpatient skilled services is not 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam you had on May 4, 2021.
You asked the Plan to waive the copayment for the eye exam. You say that this was a routine eye exam, so there should be no copayment. The Plan denied your request. The Plan says you received non-routine services, so the copayment applied correctly.
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 medical eye exams. You have been asked to pay a $10 copayment for the eye exam. We looked at the medical records to see what kind of eye exam you had. The records show that although you did receive some routine services, there were also medical services provided that were in excess of a routine eye exam. Routine eye exams do not include medical diagnosis, treatment, or evaluation of medical conditions. The records show that you were also evaluated for chronic allergic conjunctivitis and dermatochalasis of the left upper eyelid. These are medical conditions and the evaluation of them is not part of a routine exam.
That is why the eye exam you had falls within the medical eye exams 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 the eye exam you had on May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine eye exam and refraction rendered on June 18, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says you exhausted the benefit limit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services one routine eye exam with refraction per calendar year. We looked at the file and the Plan's rules. The file shows that you had two claims for a routine eye exam and refraction for June 18, 2021. The Plan paid for one claim for the routine eye exam. The second claim is not covered by Medicare or your supplemental vision benefit. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the routine eye exam and refraction rendered on June 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with your primary
care provider (PCP) on May 25, 2021.
You asked the Plan to waive the copayment for the PCP visit. You say that this was your annual wellness
exam, so there should be no copayment. The Plan says that you already received a covered annual wellness
exam with your gynecologist on May 19, 2021, so any other visits with your PCP for the year would carry a
copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 $15
copayment for PCP visits.
You have been asked to pay a $15 copayment for the PCP visit. Because you had already exhausted your
annual wellness visit on May 19, 2021, any visits with your PCP that you have for the remainder of the year
will have a $15 copayment. This means that you have been asked to pay the correct amount based on your
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit you had
with your primary care provider (PCP) on May 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a Freestyle Libre continuous glucose monitor (K0554, K0553).
You asked the Plan to pay for a Freestyle Libre continuous glucose monitor. You say that this is medically necessary. 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 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. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pay for a Freestyle Libre continuous glucose monitor (K0554, K0553).