Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the determination of refractive state (92015) provided February 15, 2021.
You asked the Plan to pay for the eye refraction. You say that the provider did not perform this service. The Plan denied your request. The Plan says the service as billed is not eligible for coverage since it was not rendered by a vision provider.
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 when rendered by through the Plan's vision vendor's specified vision network. We looked at the file and the Plan's rules. In this case the vision services as billed were not provided through the Plan's vision vendor's specified vision network. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015) provided February 15, 2021.
Your complaint about issues with billing by the 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 Based on the documentation provided, it is my opinion that the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee appears to have reached a new plateau in function. 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, 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 the admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services provided March 12, 2020.
You asked the Plan to pay for the acupuncture services. You say that you believe the denial is wrong due to the fact that the office visit was for acupuncture services. You were told by Medicare that ll you needed to have covered acupuncture services was a diagnosis of low back pain and a doctor. The Plan denied your request. The Plan says this service is not covered under the Plan's benefits.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, per page 112 of the EOC, the health plan contract says that acupuncture services are only available under the Optional Supplemental Benefit plan for an additional premium. The enrollee did not enrollee into this optional benefit. Therefore, we decided that the Plan does not have to pay for the acupuncture services provided March 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and
each subsequent 15 minute increment of deep sedation/general anesthesia (D9223) provided on February 16,
2021, and February 17, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation and deep sedation/general
anesthesia. You say that you believe the sedation/general anesthesia was medically necessary. The Plan denied
your request. The Plan says these services are non-covered dental 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 the problem focused limited oral evaluation (D0140) and each subsequent 15 minute increment of deep sedation/general anesthesia (D9223) provided on February 16, 2021, and February 17, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
You asked the Plan to pre-approve SNF care. You say that the enrollee needs assistance which home health cannot provide. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.
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 the enrollee does not have daily skilled
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on
an inpatient basis in a Skilled Nursing Facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you do not need
daily skilled therapy or nursing services.
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 from a nursing perspective, you received oral medications, had stable vital signs, and your lungs
were clear. There are no identifiable skilled nursing service needs. Regarding rehab services, you were at a
modified independent assist level with functional mobility. You required varying assist with activities of daily
living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or
therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an
inpatient basis in a SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the step therapy requirement is not met.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has bilateral knee
osteoarthritis. She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do
not show that the required drugs would be contraindicated or less effective; therefore, Gelsyn is not reasonable
or 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Gelsyn.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services to be provided by an out-of-network provider.
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services are available 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 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 services to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion Interspinous device, represented by CPT code(s) 22869 and 22870.

You asked the Plan to pre-approve Vertiflex Superion Interspinous device. You say that the device is medically necessary. The Plan denied your request. The Plan says the device is not medically necessary or reasonable.

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 Vertiflex Superion Interspinous device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental; more research is needed to show safety and efficacy of the device. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex Superion Interspinous device have not been met. Specifically, the rules say that experimental and investigational devices are not covered.

Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion Interspinous device, represented by CPT code(s) 22869 and 22870.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF services. You say that you would get much more rehab at a facility than at home. The Plan denied your request. The Plan says you do not have daily skilled nursing or rehab needs.

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 are able to ambulate household distances with a wheeled walker and contact guard assistance. You require supervision or contact-guard assistance for transfers and bed mobility. You do not require skilled nursing or skilled therapy services on a daily basis. You are medically stable. You do not have any parental medication, complex wound care or nutrition given via a feeding tube. You are medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or near baseline and you can receive services at a lower level of care. Therefore, an admission to a SNF 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 a skilled nursing facility (SNF) admission and services.
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 current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of "moderate" spinal stenosis (including the planned level of implantation L4-L5). FDA contraindications include spinal instability,
scoliosis, obesity, and osteoporosis (which have not been adequately addressed in the medical records). There is no discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in this enrollee. Overall, there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion interspinous device at L4-L5 is 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to approve additional routine transportation trips.
You asked the Plan to approve these services. You say that you need transportation to ulcer care appointments.
The Plan denied your request. The Plan says you have exhausted the benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 24 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for a psychotherapy office visit (90837) provided on February 3, 2021.
You asked the Plan to pay for a psychotherapy office visit. You say that the services provided are a covered service. The Plan denied your request. The Plan says that services were provided by an out-of-network provider without prior authorization
The Plan must follow Medicare rules. Medicare rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. The Plan rules say that they will cover services from either network or out-of-network providers, as long as the services are covered benefits and are medically necessary. The Plan contract also says that a referral or prior authorization is not required to receive services from out-of-network providers. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a psychotherapy office visit have been met. Specifically, the contract with the Plan states that a referral or prior authorization is not required for services rendered by an out-of-network provider. Therefore, we decided that the Plan has to pay for a psychotherapy office visit (90837) provided on February 3, 2021.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion at a tertiary level provider.
You asked the Plan to pre-approve a second opinion at a tertiary level provider. You say that the request for a second opinion at a tertiary level provider is medically necessary. The Plan denied your request. The Plan says the request for a second opinion at a tertiary level provider is not medically necessary as the enrollee can receive a second opinion with an in-network, non-tertiary level provider.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 second opinion at a tertiary level provider. Our reviewer says that the request for a second opinion at a tertiary level provider is not medically necessary as the enrollee can receive a second opinion with an in-network, non-tertiary level provider. Our physician reviewer found the enrollee is with scans suggestive of renal carcinoma. The requested second opinion can effectively be given by an in network, non-tertiary level provider. 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 second opinion at a tertiary level provider have not been met. Therefore, we decided that the Plan does not have to pre-approve a second opinion at a tertiary level provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to approve additional routine transportation trips.
You asked the Plan to approve these services. You say that you have appointments you need to go to. The Plan denied your request. The Plan says you have exhausted the benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an intraoral complete series of radiographic images (D0210) provided on February 16, 2021.

You asked the Plan to pay for a comprehensive oral evaluation, and an intraoral complete series of radiographic images. You say that you had to change providers and you were not aware of the frequency limitation for these services. The Plan denied your request. The Plan says the services are a covered benefit, but you have exceeded the frequency limit of one every 3 Plan years.

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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, and an intraoral complete series of radiographic images have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on April 16, 2019. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an intraoral complete series of radiographic images (D0210) provided on February 16, 2021.