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

We decided that the Plan does not have to pay for out of network physician services provided on November 17, 2020.
You asked the Plan to pay for out of network services. You say that you were referred out of network by your physician. The Plan denied your request. The Plan says you do not have a referral on file and did not have prior authorization from the Plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 out of network physician services provided on November 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro2 motion device, upper extremity assistive device (L8701).

You asked the Plan to pre-approve the MyoPro2 device. You say that given that traditional therapies had been tried and failed, the enrollee has been referred by his family practice physician for myoelectric orthotic restoration. The Plan denied your request. The Plan says the MyoPro2 device does not have full FDA approval and is deemed experimental and investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MyoPro2 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro2 motion device, upper extremity assistive device (L8701).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member's care needs can be met in the skilled nursing facility setting once stable.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.
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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for left leg weakness. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repairs to your manual wheelchair.

You asked the Plan to pre-approve the repairs. You say that the manual wheelchair is lighter and easier for your mother to lift. The Plan denied your request. The Plan says a duplication of services is not covered.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 

The file shows that you have a power wheelchair. The power wheelchair serves the same purpose as the manual wheelchair. Therefore, we decided that the Plan does not have to pre-approve repairs to your manual wheelchair.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a cochlear implant.
You asked the Plan to pre-approve the implant. You say that this is medically necessary. The Plan denied your
request. The Plan says that the criteria is not met.
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 has not substantiated their denial. The rendering providers for these
services are contracted with the plan. Records from these providers should have been made available as these
providers are agents of the plan. Therefore, we decided that the Plan has to pre-approve a cochlear implant.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies haven't proven that this device is helpful for treatment of the health problem.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found 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 the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH Admission is medically necessary. The Plan denied your request. The Plan says the enrollee can receive the same services at the current level of care.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 

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 LTACH services have not been met.

Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare.
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested procedure remains experimental for low back pain. More research is needed to show safety and efficacy of the procedure as a treatment for low back pain. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH Admission is medically necessary. The Plan denied your request. The Plan says the enrollee can receive the same services at the current level of care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implants (D6010) for teeth # 5, 6, 11, and 12.
You asked the Plan to pre-approve the dental services. You say that these implants are necessary for your quality of life. You say that you have a severe gag reflux that has worsened since getting dentures. You also say that your lifestyle has been negatively affected. The Plan denied your request. The Plan says routine dental services are not covered by Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve implants (D6010) for teeth # 5, 6, 11, and 12.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the respiratory panel rendered on November 2, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.

The Plan must follow Medicare rules. The rules say that tests that include more than 5 viral pathogens are non-covered.

We looked at the file and Medicare rules. The file shows that the testing was for more than five pathogens. 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 pay for the respiratory panel rendered on November 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) and an expandable controller (E2377) with controller harness (E2313) and electronic connections for two or more power seating systems (E2311) for use with an approved power wheelchair.
You asked the Plan to pre-approve the requested power wheelchair accessories/components. You say that you believe that all requested items should be approved due to medical necessity. The Plan denied your request. The Plan says a power seat elevation feature is noncovered by Medicare. In addition, the expandable controller and related hardware are not medically necessary for you in order to use the power features of your approved wheelchair.
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 requested power wheelchair accessories/components. Our reviewer says that the requested expandable controller is not shown to be medically reasonable and necessary in this case. Our physician reviewer found the patient does not need to operate 3 or more powered seating actuators through the drive control. The patient's strength and function in the upper extremities supports that the patient can control any power options through their own individual switches. In addition, the power seat elevator is not covered by Medicare because it is not found to be primarily medical in nature. 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 requested power wheelchair accessories/components have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300) and an expandable controller (E2377) with controller harness (E2313) and electronic connections for two or more power seating systems (E2311) for use with an approved power wheelchair.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 29, 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the Covid executive order for treatment in place. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 29, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on November 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve marriage counseling services to be provided by an out-of-network provider.

You asked the Plan to pre-approve marriage counseling services. You say that you need couples therapy and need a referral to this out-of-network therapist. You say that this is medically necessary therapy. The Plan denied your request. The Plan says this service can be received from in-network providers.

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 marriage counseling services to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pneumatic compressor, segmental home model without calibrated gradient pressure (E0651) and segmental gradient pressure pneumatic appliance (E0673) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the pneumatic compressor device and appliance. You say that you are asking for a gap exception. Upon research, you are not able to find another DME provider who offer's your services in the enrollee's area. The Plan denied your request. The Plan says enrollee's must receive their
medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. This item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. 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 Pneumatic compressor, segmental home model without calibrated gradient pressure (E0651) and segmental gradient pressure pneumatic appliance (E0673) to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to reimburse you for ophthalmological services; medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, (92004) provided on
January 15, 2021.
You asked the Plan to reimburse you for the ophthalmological services. The Plan denied your request. The Plan says that you are responsible for submitting the out-of-network claim form with itemized receipt with to the Plan's vision provider.
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the Plan covers a routine eye exam (1 per calendar year). The eye exam will include refraction and dilation with a $75 allowance. The file does not identify if the provider is out-of-network, which would require the claim to be sent to the Plan's vision provider for payment. It is noted that your claim was mailed to the Plan's vision provider based on the address on the envelope. Therefore, we decided that the Plan has to reimburse you for ophthalmological services; medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, (92004) provided by EyeMed on January 15, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance (D4910), and an unspecified preventive procedure (D1999) provided on December 14, 2020.

You asked the Plan to pay for periodontal maintenance, and an unspecified preventive procedure. You say that you want the Plan to pay for the services. The Plan denied your request. The Plan says the services at issue are not covered 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 periodontal maintenance (D4910), and an unspecified preventive procedure (D1999) provided on December 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bone replacement graft (D4263) and four extractions (D7140), provided on October 27, 2020.

You asked the Plan to pay for bone replacement graft and extractions. You say that the services should be covered. The Plan denied your request. The Plan says you have exceeded the Plan's maximum benefit.

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. Specifically, the cost of your services exceeds the Plan's dental allowance, and therefore, you are responsible for the difference.

Therefore, we decided that the Plan does not have to pay for bone replacement graft (D4263) and four extractions (D7140), provided on October 27, 2020.