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

We decided that the Plan does not have to pre-approve out-of-network dermatology visits.

You asked the Plan to pre-approve out-of-network dermatology visits. You say that you do not want to switch your primary care physician to see specialists in this medical group. The Plan denied your request. The Plan says services are available in-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 out-of-network dermatology visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wheelchair ramp and treads (E1399) provided October 5, 2020.

You asked the Plan to pay for a wheelchair ramp and treads. You say that this device was necessary to get in and out of your house. The Plan denied your request. The Plan says this is not a covered service.

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 pay for a wheelchair ramp and treads (E1399) provided October 5, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve left leg endovascular surgery.

You asked the Plan to pre-approve left leg endovascular surgery. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.

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 left leg endovascular surgery. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found there is satisfactory documentation of lifestyle limiting claudication and satisfactory documentation of significant peripheral artery disease in the leg in question. The proposed plan is appropriate and reasonable. Furthermore, you have already undergone endovascular revascularization of the left leg. As your symptoms are bilateral, not intervening on the right leg would render the recently performed procedure almost useless as both legs need to be revascularized for you to improve your walking distance. Recommend coverage. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of left leg endovascular surgery have been met. Therefore, we decided that the Plan has to pre-approve left leg endovascular surgery.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can stay in the hospital to finish treatments.

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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX (Hyaluronate sodium).

You asked the Plan to pre-approve Supartz FX (Hyaluronate sodium).. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Supartz FX (Hyaluronate sodium). Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee pain in both knees due to arthritis. The documentation does not support that the enrollee has tried and failed Orthovisc and Monovisc. The documentation does not support that Orthovisc and Monovisc would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz FX (Hyaluronate sodium). have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz FX (Hyaluronate sodium).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous airway pressure device.

You asked the Plan to pre-approve continuous airway pressure device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested device.

The Plan must follow Medicare rules. Medicare rules say that use of a continuous airway pressure device is covered when the enrollee has used the device greater than or equal to 4 hours per night on 70% of the nights. 

We looked at the file and Medicare rules. Review of the file shows that you only used the device for 28% of the nights at greater than four hours a night. This means you did not meet adherence rules for the requested item. Based on this information, we decided that Medicare rules for coverage of continuous airway pressure device have not been met. Therefore, we decided that the Plan does not have to pre-approve continuous airway pressure device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit, an outpatient hospital visit, an inpatient hospital stay, an emergency room visit, and an x-ray provided by participating providers on July 13, 2020, to October 8, 2020.

You asked the Plan to waive the copayment for an office visit, an outpatient hospital visit, an inpatient hospital stay, an emergency room visit, and an x-ray. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct copayments have been applied.

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 a $35 copayment for physician/practitioner services/in-network/specialist, a $375 copayment for outpatient hospital services/in-network, a $375 copayment per day for days 1-4. There is a $0 copayment for additional days for an inpatient hospital stay, a $90 copayment for emergency care/in-network, and a $14 copayment for outpatient diagnostic tests/in-network/x-rays.

You have been asked to pay a total of $903.

An office visit falls within the physician/practitioner services/in-network/specialist benefit category. An outpatient hospital visit falls within the outpatient hospital services/in-network benefit category. An inpatient hospital stay falls within the inpatient hospital care/in-network benefit category. An emergency room visit falls within the emergency care/in-network benefit category. An x-ray falls within the outpatient diagnostic tests/in-network/x-rays benefit category. 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 waive the copayment for an office visit, an outpatient hospital visit, an inpatient hospital stay, an emergency room visit, and an x-ray provided by a participating providers on July 13, 2020, to October 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the strongback ergonomics lightweight manual wheelchair.

You asked the Plan to pre-approve the strongback ergonomics lightweight manual wheelchair. You say that you would like reconsideration because the requested wheelchair is medically necessary. The Plan denied your request. The Plan says the requested wheelchair is upgraded and the upgrade is considered a convenience item.

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 strongback ergonomics lightweight manual wheelchair. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the member cannot propel himself in a standard wheelchair in the home. The requested wheelchair appears to exceed the member's medical 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 strongback ergonomics lightweight manual wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve the strongback ergonomics lightweight manual wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.

You asked the Plan to pre-approve the physician's services to be provided by the out-of-network provider. The Plan denied your request. The Plan says the requested services are not emergent/urgent and further podiatry care can be provided 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 services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cervical traction device (E0856).

You asked the Plan to pre-approve a cervical traction device. You say that this device is recommended by the enrollee's physical therapist for continued maintenance and pain management. The Plan denied your request. The Plan says this is not a covered device.

The Plan must follow Medicare rules. Medicare rules say that E0856 describes a cervical traction device that can be used with ambulation. Therefore, it will be denied as not reasonable and necessary. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a cervical traction device have not been met. Therefore, we decided that the Plan does not have to pre-approve a cervical traction device (E0856).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive cardiac gene panel testing provided on September 1, 2020.

You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because screening asymptomatic patients for cardiovascular risk is excluded from Medicare coverage except for specific tests.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The documentation does not show that this testing as ordered to evaluate specific signs and symptoms of a disease, or that the tests results were requested to guide treatment or therapeutic decision-making. Medicare does not cover these tests for screening purposes. Therefore, we decided that the Plan does not have to pay for comprehensive cardiac gene panel testing provided on September 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gingivectomy or gingivoplasty (D4212), gingival
irrigation (D4921), surgical placement of implant body: endosteal implant (D6010), prefabricated abutment
(D6056), and abutment supported porcelain/ceramic crown (D6058).

You asked the Plan to pre-approve the gingivectomy or gingivoplasty, gingival irrigation, endosteal implant,
prefabricated abutment, and abutment supported crown. You say that this is a recommended treatment plan that
is in the best interest of the enrollee. The Plan denied your request. The Plan says these services are not covered
under the enrollee's benefit package.

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 a
gingivectomy or gingivoplasty (D4212), gingival irrigation (D4921), surgical placement of implant body:
endosteal implant (D6010), prefabricated abutment (D6056), and abutment supported porcelain/ceramic crown
(D6058).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient office visit (99205) Urinalysis (81003) provided on August 18, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that please see attached reports and review charges. 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 pay for 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for outpatient office visit (99205) Urinalysis (81003) provided on August 18, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interlaminar spacer device (Vertiflex).

You asked the Plan to pre-approve Vertiflex. You say that this treatment is considered safe and effective and is medically necessary for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex is experimental/investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show the safety and efficacy of this device. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interlaminar spacer device (Vertiflex).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation system rental (E0483).

You asked the Plan to pre-approve this item. You say that a high frequency chest wall oscillation system is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a high frequency chest wall oscillation system.

The Plan follows Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are covered for enrollees who have been diagnosed with cystic fibrosis, bronchiectasis, or a neuromuscular disease, and there must be well-documented failure of standard treatments to adequately mobilize retained secretions.

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 this item. Our reviewer says that the enrollee does not meet criteria for coverage of a high frequency chest wall oscillation system. Our physician reviewer found that treatment with a high frequency chest wall oscillation system is not considered medically necessary for this patient. There is no diagnosis of cystic fibrosis, a neuromuscular disease, or bronchiectasis. There is insufficient evidence that this treatment is beneficial for chronic obstructive pulmonary disease (COPD), and Medicare does not cover a high frequency chest wall oscillation system for this diagnosis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this item have not been met. Therefore, we decided that the Plan does not have to pre-approve a high frequency chest wall oscillation system rental (E0483).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.

You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the Vertfilex procedure is not medically necessary and reasonable as the service is considered experimental and investigational.

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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy before coverage can be considered.

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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110).

You asked the Plan to pre-approve the dental item. You say that you need this denture. The Plan denied your request. The Plan says coverage for an upper denture is limited to one every 5 plan years. The Plan also says that the frequency limit has been reached.

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 and complete upper denture is listed as a covered service, the frequency limit has been reached. The record shows that the Plan paid for a complete upper denture that you received on May 10, 2018. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).