Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pre-approveophthalmology management. We decided that the Plandoes not have to pre-approveelectroretinography (ERG). You asked the Plan to pre-approvethe services. You say that glaucomatous optic atrophy is a covered diagnosis.The Plan says that this is considered experimental and investigational.We decided that the Planhas to pre-approveophthalmology management. The Plan follows Medicare rules. Medicare rules say that visual evoked potentials are covered for specific indications.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 for visual evoked potentials (ophthalmology management). Our reviewer says that the requested services are medically reasonable and necessary. Our physician reviewer found that VEPs are appropriate to evaluate diseases of the optic nerve, including optic nerve injury or atrophy. The enrollee has diagnoses of non-exudative age-related macular degeneration, left eye, early dry stage, and glaucomatous opticatrophy, bilateral. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ophthalmology management have been met.Therefore, we decided that the Plan has to pre-approveophthalmology management. We also decided that the Plandoes not have to pre-approveelectroretinography (ERG).The Plan follows Medicare rules. Medicare rules say that the use of ERG for glaucoma is considered experimental and investigational.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 for the ERG. Our reviewer says that the requested ERG is not medically reasonable or necessary. Our physician reviewer found that ERG coverage is excluded for patients with glaucoma.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of electroretinography (ERG) have not been met.Therefore, we decided that the Plan does not have to pre-approveelectroretinography (ERG).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 toopen 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-approvea consultation, ultrasound, and urinalysis to be provided by out of network provider, "the provider".You asked the Plan to pre-approvethese out of network services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services can be provided by a network provider.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 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. 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-approvea consultation, ultrasound, and urinalysis to be provided by out of network provider, "the provider".
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe inCourage Airway Clearance Therapy to be provided by an out of network provider,.You asked the Plan to pre-approvea high frequency chest wall oscillation device. You say that the enrollee would clearly benefit from this medically necessary device.The Plan denied your request. The Plan says no clinical information was provided to indicate that the requested services are different from the services available in network.Medicare rules say that plans can require enrollees to getcare 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 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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that thePlan does not have to pre-approvethe inCourage Airway Clearance Therapy to be provided.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea magnetic resonance imaging (MRI) of the lumbar spine.You asked the Plan to pre-approvethe MRI. The Plan denied your request. The Plan says an MRI is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 MRI. Our reviewer says that the requested MRI is not medically reasonable and necessary. Our physician reviewer found that the enrollee reportedly has back pain. No history regarding the back pain is documented. No related review of systems or physical examination is documented. The provider assessed left side back pain, though the documentation does not note a location of the back pain. The radiology report notes an indication of right side back pain. There is no documentation of the enrollee's response to prescribed therapies. As such, the incomplete and contradictory documentation submitted for review is insufficient to support that the requested MRI is currently medically necessary or reasonable.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 MRI have not been met.Therefore, we decided that the Plan does not have to pre-approvea magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider.You asked the Plan to pre-approve specialist services. You say that the specific therapy you need is not offered.The Plan denied your request. The Plan says there are in-network providers available for the specialist services you need.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 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. 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 out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe medical services to be provided by an out of network (OON) provider.You asked the Planto pre-approvethe OON dialysis services. You say that you feel that you should be allowed to go to this facility.The Plandenied your request. The Plansaysthere is no reason noted that dialysis services cannot be provided by the nearby network facility. As there is no network deficiency, the OON services are not necessary.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 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/servicesat issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plandoes not haveto pre-approvethe medical services to be provided.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve eyeglasses (lenses and frames).You asked the Plan to pre-approve the eyeglasses. You say that you had cataract surgery on both of your eyes and you have lost your eyeglasses and would like coverage for another pair of eyeglasses. The Plan denied your request. The Plan says that your eyewear benefit will renew again on May 1, 2021.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 up to $200 for eyeglasses every two years.We looked at the file, Medicare's rules and the Plan's rules. The file shows that the eyeglasses you received in March of 2019 were covered under the Medicare post cataract eyewear benefit. The file does not show that you have used your routine eyewear benefit. You are eligible to receive the routine eyewear benefit. Therefore, we decided that the Plan has to pre-approve the requested eyeglasses (lenses and frames). 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 incontinence supplies.You asked the Plan to pre-approve incontinence supplies. You say that you feel you should be approved because these were approved in the past. You had surgical removal of prostate cancer in 2013 and is now having problems holding urine.The Plan denied your request. The Plan says this item is not a covered 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve miscellaneous, custom ramp (E1399) to be provided.You asked the Plan to pre-approve the ramp. You say that the enrollee requires a modular ramp, permanent fixture and the longest portable ramp available is only 10' which would be unsafe to provide.The Plan denied your request. The Plan says custom ramp is not a covered benefit due to requirements of alterations or improvement to real property.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 miscellaneous, custom ramp (E1399) to be provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by out of network provider, "the provider" You asked the Plan to pre-approvethe home INR monitoring. You say that you are requesting an appeal of the denied service.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says if an enrollee requires medical care that Medicare requires the plan to cover and there are no in-network providers who can provide the care then the enrollee can receive the care from an out-of-network provider. The plan has confirmed that there are providers in-network available to provide the requested service.Medicare rules say that plans can require enrollees to getcare 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 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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that thePlan does not have to pre-approvethe medical services to be provided by out of network provider, "the provider".
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by out of network provider, "the provider".You asked the Plan to pre-approvespecialist services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says there are in-network providers available for these 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 pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers, "the doctor", available who can provide the items/services at issue in thisappeal. 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-approvethe medical services to be provided by out of network provider, "the provider".
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional personal care service hours. You asked the Plan to pre-approve the additional hours. You say that this is medically necessary, and the hours should not be reduced. The Plan denied your request. The Plan says 28 hours of care is necessary per week, instead of 35. 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 additional hours. Our reviewer says that the requested additional hours are not considered medically reasonable and necessary in this case. Our physician reviewer found you do not meet criteria for coverage of the additional aide hours. You were evaluated and scored for a total of 28 hours per week. The records do not support the additional hours are medically necessary. The additional hours exceed your need. 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 hours have not been met. Therefore, we decided that the Plan does not have to pre-approve additional personal care service hours.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 17 additional home health physical therapy visits (G0151).
You asked the Plan to pre-approve additional home health physical therapy visits. You say that you still have problems from your surgery. The Plan denied your request. The Plan says you no longer need skilled therapy.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 additional home health physical therapy visits. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found your ongoing mobility needs do not warrant skilled physical therapy and can be managed with a home exercise program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional home health physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 17 additional home health physical therapy visits (G0151).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of care with this provider.
You asked the Plan to pre-approve the continuation of care. You say that the continuation of care with this provider is medically necessary. The Plan denied your request. The Plan says the requested continuation of care is not medically necessary and the enrollee can transition to an in-network Allergist specialist.
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. This provider is not a network provider with the Plan. 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 continuation of care. Our reviewer says that the enrollee does not meet criteria to obtain coverage of care with an out of network allergy physician. Our physician reviewer found she is receiving standard of care allergen immunotherapy which can be transferred over to another allergist who is in network. 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 continuation of care have not been met.
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 the continuation of care. Therefore, we decided that the Plan does not have to pre-approve continuation of care with this provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS HF system (C2624 and 33289).You asked the Plan to pre-approve the CardioMEMS. You say that the CardioMEMS is medically necessary. The Plan denied your request. The Plan says this service 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 CardioMEMS. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device should still be considered experimental or investigational. Therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy.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 CardioMEMS have not been met.Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS HF system (C2624 and 33289).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a revision of lower back surgery.You asked the Plan to pre-approve the revision of lower back surgery. You say that the member is experiencing pain, scarring and deterioration. The Plan denied your request. The Plan says the records do not show back unsteadiness.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 revision of lower back surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no spinal instability, fracture or lesion. There is no 3rd time disc herniation.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 revision of lower back surgery havenot been met. Therefore, we decided that the Plan does not have to pre-approve a revision of lower back surgery.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 additional physical therapy visits.You asked the Plan to pre-approve the physical therapy. You say that you arein pain and the physical therapy is medically necessary. The Plan denied your request. The Plan says no documentation in your medical records that supports that the level of services would be of such complexity that it would require the skill of a therapist or their supervisionThe 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 determineif the Plan was correct in denying the request to pre-approve the physical therapy. 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 or that the services can be safely and effectively performed only by a therapist. At this point you can be safely transitioned to a home program.
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 physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 additional physical therapy visits.