Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome health skilled nursing services.You asked the Plan to pre-approvehome health skilled nursing services. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says there is no documentation that you are homebound and there is no order from any physician for any type of home health care for you.The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care services to be covered. The file does not show that you are homebound.Therefore, we decided that the Plan does not have to pre-approvehome health skilled nursing services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approveoffice services, testing, and treatment. You say that this is continuity of an established plan of care.The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network physician.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. No continuity of care issue is identified in this case. 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 an out of network (OON) provider.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay forthe services provided on February 28, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says that the time limit for filing has expired.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 says that the claim was filed after the timely filing limit. The claim in question was filed within one year of the date of service,which means it was filed within the time frame. The plan has not provided documentation to substantiate its denial.Therefore, we decided that the Plan has to pay forthe services provided on February 28, 2019.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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approveMagnetic Resonance Imaging (MRI) of the Lumbar spine (72148).You asked the Plan to pre-approvethe MRI. You say that the MRI is medically necessary.The Plan denied your request. The Plan says that rules for coverage were not met.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. Weasked 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 coverage criteria has been met. Our physician reviewer found in this case while it is noted that the patient has a history of low back pain, her neurological examination showed multiple abnormal findings. Notably there was bilateral lower extremity weakness, lower extremity hyperreflexia and spasticity. These abnormal findings do raise concern for myleopathy (or another compressive process) for which there may be a need for interventional management. Performance of an imaging study would be useful in the ongoing management of the patient's conditionWelooked 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 been met.Therefore, we decided that the Plan has to pre-approveMagnetic Resonance Imaging (MRI) of the Lumbar spine (72148).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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional non-emergency transportation services (A0100).You asked the Plan to pre-approveadditional non-emergency transportation services. You say that the services are necessary since you are having difficulty getting transportation.The Plan denied yourrequest. The Plan says the benefit has been exhausted. Therefore, coverage criteria has not been met.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 routine transportation 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 pre-approveadditional non-emergency transportation services (A0100).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelumbar decompression surgery (63047).You asked the Plan to pre-approvelumbar decompression surgery. You say that this is medically necessary.The Plan denied your request. The Plan says the documentation does not show that the enrollee has significant nerve pinching in his spine.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 lumbar decompression surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation submitted does not show that the enrollee has severe stenosis. The requested lumbar decompression surgery is not medically indicated.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar decompression surgery have not been met.Therefore, we decided that the Plan does not have to pre-approvelumbar decompression surgery (63047).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea mammogram screening to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe OON services. You say that you had a bad history with an in-network provider.The Plan denied your request. The Plan says the same service is available within the 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 OON services.Therefore, we decided that the Plan does not have to pre-approvea mammogram screening 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-approvea personal emergency response system.You asked the Plan to pre-approvea personal emergency response system. You say that you have a hard time walking and you are alone without a phone so you need a personal emergency response system.The Plan denied your request. The Plan says personal emergency response systems are not covered by Medicare or the Plan.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.Personal emergency response systems are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approvea personal emergency response system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea seat elevator for a power wheelchair.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit, because it is non-medical in nature.The Plan must follow Medicare rules. The rules say that for equipmentto 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 orinjured.Therefore, we decided that the Plandoes not haveto pre-approvea seat elevator for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea scooter with 16" tires (E1399).You asked the Plan to pre-approvethe non-standard scooter. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the records do not show a need for a special scooter with 16" wheels.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approvea scooter with 16" tires (E1399).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a percutaneous laminotomy (0275T).You asked the Plan to pre-approve the percutaneous laminotomy. You say that the member meets the inclusion/exclusion criteria as outlined by Medicare for coverage of this service. The Plan denied your request. The Plan says that the records indicate that the member is not enrolled in an approved study.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 records indicate that this service is intended to be provided within the CED study. The Plan has not included any information to indicate that the member is not enrolled in an approved study. Therefore, we decided that the Plan has to pre-approve a percutaneous laminotomy (0275T). 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-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that one of your legs is shorter than the other so you have a medical need for the shoe lift.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to a urologist.You asked the Plan to pre-approvethese services. You say that you have painful kidney stones.The Plan denied your request. The Plan says the referral 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 these services. Our reviewer says that the referral is not medically necessary. Our physician reviewer found the submitted records show that you have chronic pain that was evaluated by your primary care physician on December 20, 2019. The results of this visit were not provided for review. An ultrasound was performed on January 14, 2020 that revealed a probable kidney stone that was three millimeters in size. The records do not support that a referral to urology is needed at this time, as the kidney stone is not more than 10 millimeters in size and there is no documentation of multiple stones or a urinary tract infection.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-approvea referral to a urologist
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvesacroiliac spinal fusion for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaystherequested surgery cannot be approved.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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found SI joint fusion remains experimental for the treatment of back pain. Thereis no documented instability, fracture, or lesion. This fusion is not 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 services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvesacroiliac spinal fusion for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvefoot orthotics.You asked the Planto pre-approvefoot orthotics. You say that you feel that these are necessary for you and that they should be covered.The Plandenied your request. The Plansaysthis item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plandoes not haveto pre-approvefoot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecore build up (D2950) for tooth # 19.You asked the Plan to pre-approvethe core build up. You say that tooth # 19 requires full coverage restoration to restore it to optimal strength and function. You say that the entire distal half of the tooth has fractured off and less than 50% of the occlusal surface remains. You also say that without a full coverage restoration, the tooth will inevitably fracture and become non-restorable with time.The Plan denied your request. The Plan says core build up is not listed as a covered service.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, core build up is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvecore build up (D2950) for tooth # 19.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean electronic connection for the enrollee.You asked the Plan to pre-approvean electronic connection. You say that without this accessory, the beneficiary would not be able to control the chair.The Plan denied your request. The Plan says that it is not medically necessary to control the approved power options through the joystick.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 therelevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an electronic connection. Our reviewer says that an electronic connection is not medically reasonable and necessary for the enrollee in this case. The records do not indicate an electronic connection will serve to markedly optimize MRADL functioning or mobility. This is not a required accessory. As such, it is a convenience item and deemed not medically necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for an electronic connection.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 electronic connection have not been met.Therefore, we decided that the Plan does not have to pre-approvean electronic connection for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedental implants for the upper arch.You asked the Plan to pre-approvethe dental services. You say that you need the implants for your oral and aesthetic health. You say that your partial denture loosens often. You say that you have to adjust it often. You also say that you cannot afford the implants on your own.The Plan denied your request. The Plan says implants are not covered for the top arch.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 dental implants for the upper arch are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvedental implants for the upper arch.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea dental extraction performed by an oral surgeon.You asked the Plan to pre-approvea dental extraction performed by an oral surgeon. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the supplemental dental services offered by the Plan are only covered when performed by a participating general dentist.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 dental extraction to be performed by an oral surgeon is not among those covered under this benefit, as your contract with the Plan clearly states that dental services must be performed by a participating general dentist in order to be covered.Therefore, we decided that the Plan does not have to pre-approvea dental extraction performed by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approvea Pro Trach Valve as in-network.You asked the Plan to pre-approvethe Pro Trach Valve as in-network equipment. You say that the enrollee is only able to talk normally with this device.The Plan denied your request. The Plan says that the supplier isout-of-network and the enrollee can use the out-of-network benefit.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Pro Trach Valve as in-network equipment. Our reviewer says that the requested item is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee meets the criteria for the device. The enrollee has a tracheostomy for history of subglottic and tracheal stenosis. The standard speaking valve used for a tracheostomy is the passy muir valve. However, the enrollee had difficulty with phonation with that valve. There are not many alternatives to the passy muir valve. The ATOS device is an alternative. The enrolleetried it with speech pathology andhad a good result that allowed the enrolleeto phonate. The device has anHME filter which is important for good respiratory care and maintenance. The device also has a speaking valve that allows the enrolleeto phonate. There is not an alternative to this product. The enrolleemeets the requirement for aPro Trach Valve from a non-contract supplier, as in-network. The Plan should provide a (brand specific) Pro Trach Valve as in-network.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decidedthat Medicare rules for coverage of the Pro Trach Valve as in-network equipment have been met.Therefore, we decided that the Plan has to pre-approvea Pro Trach Valve as in-network.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 decideto open the case again, we will send you a letter.