Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism.

You asked the Plan to pre-approve seat lift mechanism. You say that you have difficulty getting in and out of a chair. The Plan denied your request. The Plan says you do not meet the Medicare criteria for a seat lift mechanism.

The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met. 

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 seat lift mechanism. Our reviewer says that you do not meet the Medicare criteria for the requested seat lift mechanism. Our physician reviewer found you have arthritis in your knees and use a walker. There is no documentation that you have severe arthritis or that a seat lift is included in your treating provider's course of treatment. The records also do not show that you are completely incapable of standing from a chair in the home, and you have the ability to ambulate.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.

You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device 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 a Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is with spinal stenosis. The Vertiflex device is experimental. More research is needed to show safety and efficacy. The request is not medically necessary at this time. 

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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on March 26, 2021.

You asked the Plan to pay for the problem focused limited oral evaluation. You say that your local dentist was unable to provide anesthesia and you had another dentist provide you with an emergency visit so you could receive the extraction. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.

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, problem focused limited oral evaluation (D0140) and is limited to one procedure per plan year. The record shows that you received another problem focused limited oral evaluation (D0140) on March 26, 2021 and your problem focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on March 26, 2021.
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.

You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary to recover from surgery. The Plan denied your request. The Plan says an IRF admission is not medically necessary. Your rehabilitation needs are not complex and do not require an interdisciplinary approach with multiple specialists to oversee your rehabilitation care.

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.

Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
Medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee 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 enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy
program provided in an IRF.

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.
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.

You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says rules for IRF care have not been met.

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. Our physician reviewer found that the patient was admitted for coronary artery bypass
grafting. 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. In conclusion, 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.

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.
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 an LTACH admission is medically necessary. The Plan denied your request. The Plan says the records do not show that is it medically necessary for the enrollee to be in an LTACH in place of an acute care hospital.

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 that there is no documentation provided indicating medical necessity for 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 she is currently receiving care. 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation, prophylaxis, and bitewing x-rays provided on December 7, 2020 by an OON provider.

You asked the Plan to pay more for the periodic oral evaluation, prophylaxis, and bitewing x-rays. You say that you were never told that an OON dentist is allowed to charge their own fee. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that $132.79 was the allowable rate for the services received.

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, you are responsible for the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation, prophylaxis, and bitewing x-rays provided on December 7, 2020 by an OON provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on October 6, 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 that the denial of payment for this testing is correct, because molecular genetic screening testing is not a Medicare benefit for the diagnoses listed and was performed for screening purposes.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. 

This testing was ordered by an in-network provider, who attested to the non-screening purposes of this testing. The file does not show that the plan provided notice that genetic testing would not be covered. Under Medicare rules, this means genetic testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for genetic testing provided on October 6, 2020.

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 waive the copayment for the outpatient surgical services rendered on April 2, 2021.

You asked the Plan to waive the copayment for these services. You say that you were not told there would be a copayment. The Plan denied your request. The Plan says the copayment was applied correctly.

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 $150 copayment for each visit to an outpatient hospital facility.

Review of the file shows that you had outpatient surgical services to your eye on April 2, 2021. You have been asked to pay a $150 copayment for these services. These services fall within the visit to an outpatient hospital facility 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 the outpatient surgical services rendered on April 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiation treatment provided on March 11, 2021.

You asked the Plan to waive the coinsurance for radiation treatment. You say that you could have done surgery for free but was advised of radiation treatment. You say that you were never told there was 20% coinsurance. The Plan denied your request. The Plan says the coinsurance applied correctly.

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% coinsurance per visit for radiation therapy.

You have been asked to pay $8.36, which is 20% of the allowed amount for the radiation treatment. The allowed amount is $41.78 (20% x $41.78 = $8.36). Radiation treatment falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 coinsurance for radiation treatment provided on March 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous lysis of epidural adhesions using solution injection (62264).

You asked the Plan to pre-approve percutaneous lysis of epidural adhesions using solution injection (62264). You say that the requested percutaneous lysis of epidural adhesions using solution injection (62264) is medically necessary. The Plan denied your request. The Plan says the requested percutaneous lysis of epidural adhesions using solution injection (62264) 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 percutaneous lysis of epidural adhesions using solution injection (62264). Our reviewer says that the requested percutaneous lysis of epidural adhesions using solution injection (62264) is not medically necessary. Our physician reviewer found this enrollee has chronic low back pain. He has had trials of Physical Therapy. He takes Tramadol, Soma, Celebrex and MS Contin/ Percocet for pain. He has previously had a catheter neuroplasty which provided him with significant pain relief. The request is for a repeat procedure. This procedure is considered experimental/investigational. Therefore, the request is deemed not medically reasonable and 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 percutaneous lysis of epidural adhesions using solution injection (62264) have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous lysis of epidural adhesions using solution injection (62264).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy.

You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that this request is medically reasonable for your condition. The Plan denied your request. The Plan says your condition is not one of the covered conditions for this procedure.

The Plan follows Medicare rules. Medicare rules say that hyperbaric oxygen therapy is covered when requested for one of the conditions listed 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 hyperbaric oxygen therapy. Our reviewer says that the requested service is not medically reasonable and necessary. Our physician reviewer found that the request does not meet the Medicare coverage criteria as your condition, osteonecrosis of the mandible, is not one of the covered conditions. Further, even for covered conditions, HBO is covered as adjunctive therapy only after there were no measurable signs of healing for at least 30 days of treatment with standard wound therapy and must be used in addition to standard wound care. The review has determined that the enrollee does not have a covered indication for the requested hyperbaric oxygen therapy.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of hyperbaric oxygen therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit with a specialist for an outpatient eye exam (99214) provided on March 3, 2021, by an OON provider.

You asked the Plan to pay for an office visit. You say that you would like a one-time courtesy of the prior authorization rules for services rendered. The Plan denied your request. The Plan says services were provided by an out-of-network provider without 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 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 an office visit with a specialist for an outpatient eye exam (99214) provided on March 3, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a telehealth visit (99443) provided April 21, 2021.

You asked the Plan to waive the copayment for the telehealth visit. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was 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 $50 copayment for specialty telehealth visits.

You have been asked to pay a $50 copayment for the telehealth visit. The telehealth visit falls within the specialty telehealth visits 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 a telehealth visit (99443) provided April 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a polycarbonate lens (V2784) provided on February 25, 2021.
You asked the Plan to pay for a polycarbonate lens. You say that you received a denial letter stating you exhausted your vision benefits for the year and would like to appeal the denied service. The Plan denied your
request. The Plan says you exhausted your benefit, and you are responsible for the remaining balance. 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 contract says you have a $200 allowance once per year to use towards the purchase of frames and lenses. We looked at the file and the Plan's rules. The records show you exhausted your $200 maximum allowed benefit on February 25, 2021. The records also show that you purchased frames at an allowed amount of $87.30. The Plan paid $103 for progressive lenses and $9.70 for an anti-reflective coating. You received the total allowed amount of $200 ($103 + $87.30 + $9.70 = $200). Based on this information, we decided that the Plan's rules for coverage of a polycarbonate lens have not been met. Therefore, we decided that the Plan does not have to pay for a polycarbonate lens (V2784) provided on February 25, 2021.
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.

You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

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. Our physician reviewer found your medical conditions are stable and you have no complex nursing or rehabilitation needs. You do require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.