Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic services provided from September 2, 2020, to September 6, 2020.
You asked the Plan to pay for the therapeutic services. You say that the therapy services were medically necessary. The Plan denied your request. The Plan says you did not request prior authorization for the therapy services.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
We looked at the file and Medicare rules. You did not request prior authorization. Based on this information, we decided that Medicare rules for coverage of the therapeutic services have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic services provided from September 2, 2020, to September 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar epidural injections for the enrollee.

You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied
your request. The Plan says the injection is deemed not medically necessary as the criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the injections. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee needs a physical exam or at least a telemedicine visit before proceeding with an
interventional procedure. The request at this point, therefore, is considered not medically reasonable or
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 the injections have not been met. Therefore, we decided that the Plan does not
have to pre-approve lumbar epidural injections for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a right knee orthosis (L1833) and a suspension sleeve (L2397).

You asked the Plan to pay for a knee orthosis and a suspension sleeve. You say that the enrollee is using these medically necessary items with benefit. The Plan denied your request. The Plan says rules for payment have not been met.

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 pay for a knee orthosis and a suspension sleeve. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaint was chronic pain located in the bilateral knees. The documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. There is insufficient documentation of an evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered.

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 knee orthosis have not been met. Furthermore, the requested suspension sleeve is not separately payable when the base item is not covered. Therefore, we decided that the Plan does not have to pay for a right knee orthosis (L1833) and a suspension sleeve (L2397).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care (99306) provided on July 9, 2020, by an
OON provider.
You asked the Plan to pay for nursing facility care. You say that you would like reconsideration for payment.
The Plan denied your request. The Plan says prior authorization was not obtained. The service was not urgent
or emergent and could be provided in-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 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 pay for nursing facility care (99306) provided on July 9,
2020, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2310, K0108).

You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 the accessories. Our reviewer says that the requested accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee requires these additional accessories. The records document that the enrollee's upper extremity strength is 3+/5 on the left and 4/5 on the right with wrists and hands within functional limits. The records indicate upper extremity strength and function appear to be adequate to control the power option using its own switch.

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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2310, K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis coded L0650.

You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the item billed is not payable.

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 L0650 is not supported in the medical record. Specifically, there are no claims submitted for the enrollee from the ordering physician. Therefore, there is no evidence of an established relationship between the enrollee and the ordering physician. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis coded L0650.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99213-GT).

You asked the Plan to waive the copayment for an office visit. You say that you disagree with the copayment. The Plan denied your request. The Plan says the copayment was 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 $35 copayment for a specialist visit.

You have been asked to pay a $35 copayment for an office visit. A specialist office visit falls within the physician/practitioner services 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 office visit (99213-GT).
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 continued care is medically necessary. The Plan denied your request. The Plan says the enrollee's needs were custodial.

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 the enrollee does not have documented skilled nursing or therapy needs. The enrollee has been consistently ambulating more than 100 feet and tending to activities of daily living with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and could 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the coinsurance for the dental services.

You asked the Plan to adjust the coinsurance for the routine periodic exam and standard adult dental cleaning.
You say that you would like the Plan to cover the charges. The Plan denied your request. The Plan says you
were charged the coinsurance 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 $0
copayment, you may be billed more by an out-of-network provider if the charge is greater than the MAC for
Routine Dental Benefits.

You have been asked to pay coinsurance billed by the out-of-network dental provider. The dental charge is
greater than the MAC for the routine periodic exam and standard adult dental cleaning. 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 adjust the coinsurance for the dental services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services.

You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.

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 laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a panniculectomy/abdominoplasty.

You asked the Plan to pre-approve the requested surgery. You say that you believe that this surgery should be allowed. The Plan denied your request. The Plan says there is not sufficient documentation to show that this can be considered a reconstructive surgery. Cosmetic surgery is not covered by Medicare.

The Plan follows Medicare rules. Medicare rules say that abdominal Lipectomy/Panniculectomy is surgical removal of excessive fat and skin from the abdomen. When surgery is performed to alleviate such complicating factors as inability to walk normally, chronic pain, ulceration created by the abdominal skin fold, or intertrigal dermatitis, such surgery is considered reconstructive.

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 requested surgery. Our reviewer says that the documentation does not support that the requested surgery is reasonable and necessary. Our physician reviewer found the documentation provided includes photographs that do not demonstrate pannus beneath pubic ramus nor intertrigo. The written documentation does not indicate that the enrollee has intertrigo or other complications. The note indicates an assessment for additional procedures for body contouring. The elements of the local coverage determination have not been satisfied.

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 requested surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve a panniculectomy/abdominoplasty.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve a sacroiliac joint injection.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says that supporting documentation was not received.

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. The plan has made several attempts to one of its contract providers to receive records. The contract provider is part of the plan, and it is the plan's responsibility to receive these records. The enrollee should not be denied due to the plan's inability to receive from one of its own providers. Therefore, we decided that the Plan has to pre-approve a sacroiliac joint injection.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a myoelectric elbow-wrist-hand-finger orthosis for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered by Medicare or the plan.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. At this time the requested robotic orthosis is not proven to be more beneficial for treatment of the enrollee's medical condition/function of hemiparesis after stroke than any available standard therapy such as conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, conventional muscle strengthening, and botox for spasticity if needed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve a myoelectric elbow-wrist-hand-finger orthosis for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for cervical or vaginal cancer screening; pelvic and clinical breast examination.

You asked the Plan to pay for the cervical or vaginal cancer screening, pelvic and clinical breast examination. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 cervical or vaginal cancer screening, pelvic and clinical breast examination. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for cervical or vaginal cancer screening; pelvic and clinical breast examination.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an LSO (L0650), bilateral knee orthoses (L1833), and
suspension sleeves (L2397).

You asked the Plan to pay for an LSO, bilateral knee orthoses, and suspension sleeves. You say that the
requested items are medically necessary for the enrollee. The Plan denied your request. The Plan says rules for
payment have not been met.

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 pay for an LSO, bilateral knee orthoses, and
suspension sleeves. Our reviewer says that the requested items are not considered medically reasonable and
necessary in this case. Our physician reviewer found that the enrollee's chief complaint was chronic pain
located in bilateral knees. The case file does not contain documentation of an evaluation of the back. The available documentation in the case file does not support that the requested LSO was medically reasonable and
necessary for the enrollee in this case, according to the coverage criteria established by Medicare. A physical
examination of the back would reasonably be required to adequately assess whether the coverage criteria for an
LSO have been met. The documentation does not support that the LSO is being prescribed for one or more of
the covered indications in this case, as there is no documentation of a credible physical examination of the
back. The documentation in the case file also does not support that the requested knee orthoses with sleeves
were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria
established by Medicare. There is no documentation of recent injury to, or recent surgical procedure on, either
of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. The item
coded L2397 (sleeve) is not separately payable when the base item is not covered.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an LSO and bilateral knee orthoses have not been met. Furthermore, the
requested suspension sleeves are not separately payable when the base items are not covered. Therefore, we
decided that the Plan does not have to pay for an LSO (L0650), bilateral knee orthoses (L1833), and suspension
sleeves (L2397).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the endodontic services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the OON dental care. You say that you wish to be able to complete your treatment with the provider that you are comfortable with. The Plan denied your request. The Plan says your dental plan does not cover OON services.

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 endodontic services 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 incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that the requested disposable adult incontinence briefs are medically necessary. The Plan denied your request. The Plan says these items are not covered by Medicare or as a supplemental benefit.

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 incontinence supplies.