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

We decided that the Plan does not have to issue reimbursement of the copayment for the visual field examination (92083) provided on August 27, 2020.

You asked the Plan to issue reimbursement of the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $20 per visit for outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration. 

You have been asked to pay a $20 copayment for the visual examination provided. 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 issue reimbursement of the copayment for the visual field examination (92083) provided on August 27, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the telehealth services provided on August 28, 2020.

You asked the Plan to pay for the telehealth services. You say that the televisit was completed during the COVID-19 pandemic and was the only way to communicate and care for the enrollee safely. The Plan denied your request. The Plan says that the precertification authorization was exceeded.

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 did not provide the authorization showing what service was approved. Therefore, we decided that the Plan has to pay for the telehealth services provided on August 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation for the enrollee.

You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your
request. The Plan says the requested procedure is not indicated at this time.

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 surgery. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the criteria for vertebral augmentation not met. There is no documentation that the fracture is less than 6
weeks old. More information is needed to show that the fracture is acute and not chronic.

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 surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve percutaneous vertebral augmentation for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown, endodontic therapy, endosteal implant, custom fabricated abutment, implant supported crown, and sinus augmentation with bone or bone substitutes to be rendered by an OON provider.

You asked the Plan to pre-approve the crown, endodontic therapy, endosteal implant, custom fabricated abutment, implant supported crown, and sinus augmentation. You say that you believe this provider is in-network with your plan. The Plan denied your request. The Plan says you would like these services to be rendered by an OON provider. The Plan also says that services are only covered when they are rendered by in-network dentists.

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 covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve a crown, endodontic therapy, endosteal implant, custom fabricated abutment, implant supported crown, and sinus augmentation with bone or bone substitutes to be rendered by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty power operated scooter (K0801).

You asked the Plan to pre-approve the services. You say that this is the only scooter that will fit your body comfortably. The Plan denied your request. The Plan says the weight requirement is not met.

The Plan must follow Medicare rules. Medicare rules say that power operated vehicles have certain weight requirements. 

The case file shows that your weight is 222 pounds, which outside the range covered for your requested scooter. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty power operated scooter (K0801).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for CT scan of the chest, abdomen, and thorax out-of-network.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. 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 for CT scan of the chest, abdomen, and thorax out-of-network.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation mileage.

You asked the Plan to pre-approve the additional mileage. You say that this is medically necessary. The Plan denied your request. The Plan says this trip is beyond the coverage 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 routine transportation with up to a 50 mile one-way limit. 

We looked at your request, the records in the case file, and the rules. The requested would be 82.11 miles, over the mileage limit. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation mileage.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four pontics (D6245 x4) and two retainer crowns
(D6740 x2).

You asked the Plan to pre-approve the pontics and retainer crowns. You say that the Plan's handbook states that
bridges are covered. The Plan denied your request. The Plan says these services are not covered.

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 pre-approve four
pontics (D6245 x4) and two retainer crowns (D6740 x2).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee arthroscopy surgery with synovectomy, medial
meniscectomy, and debridement.

You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your
request. The Plan says the MRI did not show a tear of the cartilage of the knee.

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 surgery. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee cites right knee pain that is medial sided. There are feelings of giving way, having felt a pop,
stiffness, catching and weakness. The symptoms are intermittent, mild, aching, dull, radiating, throbbing, and
causing difficulty with everyday activity. Exam reveals right knee range of motion of -5 to 120. There is
effusion. Medial joint line tenderness is noted. There is quadriceps atrophy. McMurray's is positive. There is
crepitus noted. However, the MRI dated 10/29/20 shows no internal derangement of the right knee; lobulated
signal alteration contiguous with the posterior medial aspect of the joint space measuring 2.0 x 1.0 cm
consistent with a synovial or ganglion cyst; minimal osteoarthritic degenerative change. The imaging does not
corroborate pathology that would be typically indicated for such surgical treatment. There is no corroborative
evidence of meniscal tear and osteoarthritic changes are noted to be minimal. Limited reasonable conservative
measures have been trialed and failed. Therefore, the requested arthroscopy surgery with synovectomy, medial
meniscectomy, and debridement 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 the surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve knee arthroscopy surgery with synovectomy, medial meniscectomy, and debridement.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve insertion of pacemaker for the enrollee.

You asked the Plan to pre-approve the pacemaker. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no clinical information documenting medical necessity.

The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 pacemaker. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found based on the records provided, the enrollee presented with symptomatic bradycardia and although symptoms improved with discontinuation of rate control medication (propranolol) and antiarrhythmic medication (dronaderone), she requires these medications to help prevent rapid atrial fibrillation that is also documented. In this circumstance, her symptomatic bradycardia cannot be safely reversed without causing rapid atrial fibrillation. The documentation does support the medical necessity for permanent pacemaker placement. 

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 pacemaker have been met. Therefore, we decided that the Plan has to pre-approve insertion of pacemaker for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiac monitoring services provided on July 8, 2020 by an out of network provider.

You asked the Plan to pay for the cardiac monitoring services. You say that services were ordered by a contracted provider. The Plan denied your request. The Plan says you did not request prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the cardiac monitoring services provided on July 8, 2020 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve progressive lens inserts (V2784) provided October 26, 2020.

You asked the Plan to pre-approve the lens inserts. You say that the eyewear should be covered. The Plan denied your request. The Plan says coverage is limited to one pair of standard eyeglasses or contact lenses. Progressive lens inserts are not covered.

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 routine eyewear up to $300 a year when obtained from network providers. 

We looked at the file and the Plan's rules. The plan did not provide evidence that this purchase was related to cataract surgery. Therefore, routine vision rules are applied. The plan's supplemental vision rules state that eyewear is only covered when obtained from network providers. The lenses at issue were obtained from an out-of-network provider. The type of lenses provided would not be covered under the cataract benefit. Based on this information, we decided that the Plan's rules for coverage of the lens inserts have not been met.

Therefore, we decided that the Plan does not have to pre-approve progressive lens inserts (V2784) provided October 26, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual screening for depression provided on June 8, 2020.

You asked the Plan to pay for the annual screening for depression. You say that the provider is balance billing you. The Plan denied your request. The Plan says you had this same service on April 27, 2020 which was paid for.

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. Only one screening per year is covered. Based on this information, we decided that Medicare rules for coverage of this screening for depression have not been met. Therefore, we decided that the Plan does not have to pay for the annual screening for depression provided on June 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide 31 additional units of dialysis with an out of network provider.

You asked the Plan to provide 31 additional units of dialysis with an out of network provider. You say that the enrollee needs dialysis. The Plan denied your request. The Plan says there are in network providers for this service.

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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 31 additional units of dialysis with an out of network provider have not been met. Therefore, we decided that the Plan does not have to provide 31 additional units of dialysis with an out of network provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a carotid artery duplex.

You asked the Plan to pre-approve a carotid artery duplex. You say that the enrollee has been seen multiple times with worsening symptoms. The Plan denied your request. The Plan says that the services in dispute are not medically necessary.

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 the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a carotid artery duplex. Our reviewer says that a carotid artery duplex is considered medically reasonable and necessary in this case. Our physician reviewer found while the enrollee has no reported symptoms or signs of extracranial carotid artery disease, he is at risk for significant carotid atherosclerosis based on his known extensive cardiovascular disease, hypertension and hyperlipidemia. Although not indicated for general screening in low risk patients, in patients with known atherosclerotic vascular disease in other territories (in this case the coronary arteries) along with poorly controlled hypertension and hyperlipidemia, AHA/ACC guidelines give carotid duplex imaging a 2B indication (may be indicated) in this specific clinical situation of a high clinical risk but asymptomatic patient. In this situation carotid duplex imaging is medically reasonable and is within the standard 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 a carotid artery duplex have been met. Therefore, we decided that the Plan has to pre-approve a carotid artery duplex.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Modafinil Tab.

You asked the Plan to pre-approve Modafinil Tab. You say that you need this drug for quality of life. The Plan denied your request. The Plan says this drug is not covered under your Medicare Part B benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Modafinil Tab.

Benefits for Modafinil Tab may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a recliner chair (A9270).

You asked the Plan to pre-approve a recliner chair. You say that the enrollee needs this item. The Plan denied your request. The Plan says this item 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 a recliner chair (A9270).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT).

You asked the Plan to pre-approve the SBRT. You say that the records provided support the medical necessity
of the requested treatment. The Plan denied your request. The Plan says the special pictures of the enrollee's
lungs did not show specific signs. The Plan says that SBRT 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 SBRT. Our reviewer says that
SBRT is not considered medically reasonable and necessary in this case. Our physician reviewer found the
enrollee appears to have an early stage non-small cell lung cancer for which SBRT would be an accepted
standard of care. However, the submitted records include no history or staging. The treatment plan is included
which suggests that the enrollee has a Stage I lung cancer (as only one lesion is being targeted). But in the
absence of any records indicating tumor stage, it cannot be determined that the treatment is within the accepted
standards 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 the SBRT have not been met. Therefore, we decided that the Plan does not have
to pre-approve stereotactic body radiation therapy (SBRT).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.

You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis with neurogenic claudication, degenerative disc disease of lumbar, and bilateral lumbar radicular pain. The requested Superion spacer is considered experimental in nature and not supported over the gold standard of lumbar laminectomy. The services are not the standard of care and are 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 a Vertiflex Superion spacer.