Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is your previous pain management doctor for the last ten years when you lived. 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 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 a referral to an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional Physical Therapy visits.
You asked the Plan to pre-approve the additional Physical Therapy visits. You say that Physical Therapy has been helpful and the member would like to continue. The Plan denied your request. The Plan says there is no evidence that the unique skills of a physical therapist are required to restore or maintain function.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional Physical Therapy visits.. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy and occupational therapy, by or under the supervision of a therapist. 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 additional Physical Therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional Physical Therapy visits.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the definitive drug testing provided on October 24, 2019.
You asked the Plan to pay for the drug testing. You say that this physician ordered his custom panel which was provided and should be covered due to medical necessity. The Plan denied your request. The Plan says that there is no order stating what tests are to be performed so this cannot be covered.
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by a treating physician. In this case, the laboratory provided a copy of the signed form indicated what is included in the ordering provider's custom panel. The lab also provided a copy of an order form indicating the intent that this custom panel be provided. We find that the denial based on no valid order is not supported. In addition, there is no indication if the ordering provider is in-network with the Plan. Therefore, we decided that the Plan has to pay for the definitive drug testing provided on October 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tumor treatment field therapy for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says this does not meet the coverage criteria as there is a diagnosis of recurrent GBM.
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 therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this therapy is indicated for the treatment of newly diagnosed glioblastoma. The enrollee's glioblastoma is not newly diagnosed, but rather was diagnosed in January 2016.
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 therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve tumor treatment field therapy for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea Hyalgan injection for the enrollee.You asked the Planto pre-approvethe injection. You say that this is medically necessary.The Plandenied your request. The Plansaysstep therapy encourages you to try our preferred agents, which are just as effective: Monovisc and Orthovisc.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 injection. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found there is no indication of a trial and failureof Orthovisc or Monovisc. The provided medical records do not indicate that the plan's required drugs would likely be less effective and/or likely have adverse effects for 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 the injection have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea Hyalgan injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bronchial thermoplasty services.
You asked the Plan to pre-approve the bronchial thermoplasty services. You say that the medical records provided support the need for the requested treatment. The Plan denied your request. The Plan says the requested treatment is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Medicare rules say that diathermy or ultrasound heat treatments for asthma, bronchitis, or any other pulmonary condition are not considered medically necessary. Based on this information, we decided that Medicare rules for coverage of the bronchial thermoplasty services have not been met. Therefore, we decided that the Plan does not have to pre-approve bronchial thermoplasty services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on September 9, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on September 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an office visit and physician services. You say that you have been referred to different specialists before and you feel like they did not help you. You say that you would like approval to see an out-of-network provider. 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 the medical services to be provided by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided to the enrollee on November 24, 2019.
You asked the Plan to pay for ambulance services. You say that the claim should be paid. The Plan denied your request. The Plan says when enrolled in hospice, Original Medicare pays for claims not the Plan.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for ambulance services provided to the enrollee on November 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 14, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says utilization of network providers is required
when possible and 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 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 has network providers
available who can provide 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 the medical services provided on June 14, 2019 by
an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214 and G8427) and provided on October 31, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an OON office visit. You say that these services were billed correctly. The Plan denied your request. The Plan says these services were not authorized.
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 has network providers available who can provide 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 an office visit (99214 and G8427) and provided on October 31, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture services to be provided.
You asked the Plan to pre-approve the acupuncture services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care 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 be 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 acupuncture services to be provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Apple Watch 5 (A9270).
You asked the Plan to pre-approve an Apple Watch 5. You say that other than the A5 there are no suitable wearable devices that do a partial EKG and store it in a watch, cell phone and be uploaded to a patient portal. The Plan denied your request. The Plan says this item is not a medical device and is 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 an Apple Watch 5 (A9270).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional wheelchair accessories (expandable controller, harness, electrical connection, quad push button, joystick tops) for the enrollee.
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says the requested additional accessories are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the accessories. Our reviewer says that the requested accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found these accessories will not serve to markedly enhance MRADL performance. They are not necessary for wheelchair function. As such, they are convenience items, and deemed 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 the accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional wheelchair accessories (expandable controller, harness, electrical connection, quad push button, joystick tops) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex interspinous spaces.
You asked the Plan to pre-approve the Vertiflex interspinous spacer. You say that the device is medically necessary for treatment of the member's condition. The Plan denied your request. The Plan says medical studies have not proven that the device is helpful for the treatment of the member'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 the Vertiflex interspinous spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental and more research is 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 Vertiflex interspinous spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex interspinous spaces.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower partial overdenture (D5866) and an extraction (D7140) for tooth #8.
You asked the Plan to pre-approve the lower partial overdenture. The Plan denied your request. The Plan says the requested overdenture is not 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 overdenture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a lower partial overdenture (D5866) and an extraction (D7140) for tooth # 8.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement surgery
You asked the Plan to waive the copayment for outpatient surgery. You say that this bill is incorrect, and this was not an emergency room visit. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $250 copayment for outpatient surgery at an outpatient hospital facility. You have been asked to pay $250 copayment for outpatient surgery. Outpatient surgery falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 wound debridement surgery
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services on October 31, 2019.
You asked the Plan to pay for ambulance services. You say that the emergency transport was unrelated to hospice services. The Plan denied your request. The Plan says Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for ambulance services on October 31, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous and/or interlaminar device 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 medical studies haven't proven that this device is helpful for treatment of the enrollee's health problem.
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 this device is considered experimental. More research is 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 an interspinous and/or interlaminar device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bridge for teeth # 4, 5, 6, 7, 8, 9, 10, and 11.
You asked the Plan to pre-approve the dental services. You say that you are entitled to $2,000 of coverage for dental services. You also say that removable prosthodontic services are listed as covered. The Plan denied your request. The Plan says the bridge is not 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 bridge is not among those covered under this benefit. The Evidence of Coverage clearly states that coverage excludes fixed bridge, implants and repairs for flexible base dentures. Therefore, we decided that the Plan does not have to pre-approve a bridge for teeth # 4, 5, 6, 7, 8, 9, 10, and 11.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided to the enrollee on July 1, 2019 to July 31, 2019.
You asked the Plan to pay for outpatient services. You say that hospice election was terminated before the dates of service. The Plan denied your request. The Plan says Original Medicare will continue to pay for services furnished after the revocation of hospice services until the first day of the month after election termination.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on July 23, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for outpatient services provided to the enrollee on July 1, 2019 to July 31, 2019.