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

We decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor (CGM) and supplies.

You asked the Plan to pre-approve the CGM and supplies. You say that the items are medically necessary. The Plan denied your request. The Plan says there is no indication the member is on insulin injections three or more times per day and requires frequent adjustments.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor (CGM) and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a tubing extension set (S1015) and infection control supplies (S8301) provided on June 29, 2021.
You asked the Plan to pay for a tubing extension set and infection control supplies. You say that these items were medically necessary. The Plan denied your request. The Plan says these items were not billed with valid codes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code S1015 and S8301 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of a tubing extension set and infection control supplies have not been met. Therefore, we decided that the Plan does not have to pay for a tubing extension set (S1015) and infection control supplies (S8301) provided on June 29, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home visits for assistance with activities of daily living and personal care (99509).
You asked the Plan to pre-approve the home visits. You say that the enrollee needs help for daily activities including mobility, cooking, and cleaning. The Plan denied your request. The Plan says the requested in-home assistance service is not covered under the enrollee's current coverage benefits.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home visits have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve home visits for assistance with activities of daily living and personal care (99509).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic parenteral drug (D9610).
You asked the Plan to pre-approve a therapeutic parenteral drug. You say that the enrollee has high blood pressure. You say that the sedation will help to control this. The Plan denied your request. The Plan says therapeutic parenteral drug is not listed as a covered 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested therapeutic parenteral drug is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a therapeutic parenteral drug (D9610).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro myoelectric orthosis (L8702).
You asked the Plan to pre-approve the orthosis. You say that the enrollee has exhausted the other available therapies and has not regained meaningful use of his left upper extremity. The Plan denied your request. The Plan says this item is considered experimental and investigational. There is insufficient evidence of its effectiveness in those with stroke and hemiparesis.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro myoelectric orthosis (L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gingivectomy and pulp cap (D4212, D3120).
You asked the Plan to pre-approve the gingivectomy and pulp. You say that these procedures are medically necessary. The Plan denied your request. The Plan says the dental services at issue are non-covered under your dental 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, 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 gingivectomy and pulp cap (D4212, D3120).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services (97113, 97110, 97162, 97112) to be provided by an out-of-network provider.

You asked the Plan to pre-approve the out-of-network physical therapy services. You say that the services are medically necessary. The Plan denied your request. The Plan says there are 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 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 (97113, 97110, 97162, 97112) to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bone graft at time of implant placement (D6104).

You asked the Plan to pay for bone graft. You say that you would like this service covered. The Plan denied your request. The Plan says this service is not covered under your benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for bone graft at time of implant placement (D6104).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre (K0554) and related supplies (K0553).
You asked the Plan to pre-approve the Freestyle Libre and related supplies. You say that the item is medically necessary. The Plan denied your request. The Plan says the member is not insulin treated with three or more daily administrations and does not require frequent adjustment.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee is not insulin-treated with multiple (three or more) daily administrations of insulin and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the Freestyle Libre and related supplies. have not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre (K0554) and related supplies (K0553).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiographic/surgical implant index (D6190), implant placement (D6010 x 3), semi-precision abutment (D6191 x 3), semi-precision attachment (D6192 x 3), and collection and application of autologous blood concentrate product.
You asked the Plan to pre-approve the dental services. You say that you have up to $4,000 for dental coverage. You say that you sincerely need these services. You say that you have no other options left. You say that without these implants, you will not be able to eat. You also say they are the only things that will keep your denture in place. The Plan denied your request. The Plan says radiographic/surgical implant index is not listed as a covered service. Implant placement is not listed as a covered service.
Semi-precision abutment is not listed as a covered service. Semi-precision attachment is not listed as a covered service. Collection and application of autologous blood concentrate product is not listed as a covered service either.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested implant and related services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve radiographic/surgical implant index (D6190), implant placement (D6010 x 3), semi-precision abutment (D6191 x 3), semi-precision attachment (D6192 x 3), and collection and application of autologous blood concentrate product.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee brace (L1845).

You asked the Plan to pre-approve a knee brace. You say that the item is medically necessary. The Plan denied your request. The Plan says there is no documentation of a recent injury or surgical procedure and there is no joint laxity or instability documented.

The Plan must follow Medicare rules. Medicare rules say that a knee orthosis, with an adjustable flexion and extension joint that provides both medial-lateral and rotation control (L1845), is covered if the member has had recent injury to or a surgical procedure on the knee(s). Knee orthosis L1845 is also covered for a member who is ambulatory and has knee instability. For code L1845 knee instability must be documented by examination of the member and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test). Claims for L1845 will be denied as not reasonable and necessary when the member does not meet these criteria. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a knee brace have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee brace (L1845).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.
You asked the Plan to pre-approve a portable ventilator. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that ventilators (E0465, E0466, and E0467) are covered when specific criteria are met. 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 a portable ventilator. Our reviewer says that the item is not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee meets the coverage criteria detailed in the Local Coverage Determination (LCD): Respiratory Assist Devices - L33800. The requested ventilator is being requested for use in a bilevel positive airway pressure (BiPAP) mode. As stated in the LCD: "Claims for ventilators used to provide continuous positive airway pressure (CPAP) or bi-level CPAP therapy for conditions described in this RAD policy will be denied as not reasonable and 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 a portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Herceptin (J9355).
You asked the Plan to pre-approve Herceptin. You say that this is medically necessary. The Plan denied your request. The Plan says this is part of a clinical trial.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve Herceptin as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Herceptin (J9355).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a remote 30 day electrocardiogram (93270) to be
provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a remote 30 day electrocardiogram. You say that you had a stroke in
September 2021 and still cannot obtain a heart monitor. You also say that your daughters have been contacting
the in-network provider and have not been able to get this resolved and all this is causing you stress. The Plan
denied your request. The Plan says that you have been offered services by an in-network provider and you have
declined these services. The Plan also says that your condition is stable at this time and not urgent or emergent.
The Plan also says that there are in-network providers within a reasonable distance from y our location that can
provide this service or item and you can find a list of in-network providers in your Provider Directory.
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 had network providers
available who could have provided the items/services at issue in this appeal. 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.
Therefore, we decided that the Plan does not have to pre-approve a remote 30 day electrocardiogram (93270) to
be provided by an out-of-network (OON) provider.
Your complaint about potentially poor customer service by the in-network 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652 and E0667).
You asked the Plan to pre-approve a pneumatic compression device. You say that the item is medically necessary. The Plan denied your request. The Plan says there is no documentation indicating the lymphedema has extended to the chest, trunk or abdomen.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652 and E0667).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit (99284) provided on September 5, 2021.

You asked the Plan to waive the copayment for the emergency room visit. You say that the services should be covered as you had to go back the next day since all your issues were not addressed during your first visit. 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. Per your contract with the Plan, the cost-sharing for emergency room visits is only waived when you are admitted to the hospital within 23 hours for the same condition. Emergency room visits fall 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 (99284) provided on September 5, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power elevating seat (E2300) for a power wheelchair.

You asked the Plan to pre-approve a power elevating seat. You say that the requested item is a necessity for your care. The Plan denied your request. The Plan says the requested item is not a Medicare-covered benefit.

The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature and power standing feature are non-covered because they are not primarily medical in nature. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power elevating seat have not been met. Specifically, the record shows that the request is for a non-covered item. Medicare does not offer coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a power elevating seat (E2300) for a power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the laser eye surgery.

You asked the Plan to pre-approve the laser eye surgery. You say that you need the laser for a better outcome for your situation. The Plan denied your request. The Plan says the records do not support medical necessity for your request.

The Plan must follow Medicare rules. The rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laser eye surgery have not been met. Specifically, medical records were not submitted to determine if the procedure is medically necessary. Therefore, we decided that the Plan does not have to pre-approve the laser eye surgery.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device is 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 a Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the Vertiflex device is experimental. More research is needed. The requested Vertiflex device is not medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the X-ray of the foot (73630) provided on August 9, 2021.  You asked the Plan to waive the copayment for the X-ray of the foot. You say that you have not been charged a copayment in the past. The Plan denied your request. The Plan says the copayment has processed correctly in this case.  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 Medicare-covered standard X-ray service.     You have been asked to pay a $15 copayment for the X-ray of the foot. This service falls within the Medicare-covered standard X-ray service 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 X-ray of the foot (73630) provided on August 9, 2021.