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

We decided that the Plan does not have to approve in-network coverage for tracheostomy supplies to be provided by an out of network (OON) provider.

You asked the Plan to approve in-network coverage for the OON tracheostomy supplies. You say that it is felt that these supplies are medically necessary and should be approved. The Plan denied your request. The Plan says coverage at the OON cost sharing was approved for these supplies from the OON provider. However, the network has suppliers able to provide the requested services. As such, the network cost sharing will only be allowed if the supplies are received from the network suppliers.

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 approve in-network coverage for 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 approve in-network coverage for these items/services. Therefore, we decided that the Plan does not have to approve in-network coverage for tracheostomy supplies to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ankle-foot orthotics and inserts to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve orthotic items. You say that you have used this supplier since you were 16 years old. The Plan denied your request. The Plan says the denial of authorization for these items is correct, because this provider is out-of-network with the Plan and these orthotics can be obtained from an in-network supplier.

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 ankle-foot orthotics and inserts to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D2740) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered 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. Therefore, we decided that the Plan does not have to pre-approve dental services (D2740) 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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 enrollee can remain at the current acute care hospital (ACH) until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care (LTC) needs.

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: Practitioner Services
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 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 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network social worker.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says outpatient visits can be done with a network provider.

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 to an out-of-network social worker
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician services with a provider who has opted out of the Medicare program.

You asked the Plan to pre-approve physician services with an opted-out provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested provider has opted out of the Medicare program. The Plan says there are equally qualified in-network specialists that can provide the same care and treatment you are requesting.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

The services at issue in this appeal are being requested to be performed by a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pre-approve physician services with a provider who has opted out of the Medicare program.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554).

You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose
monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been
met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood
glucose testing at least four times per day or use insulin with at least three daily injections. Based on this
information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met.
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight additional physical therapy visits.

You asked the Plan to pre-approve the additional visits. You say that the enrollee will not heal properly without
therapy. The Plan denied your request. The Plan says the enrollee is not improving.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

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 additional visits. Our reviewer says
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific
and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee
has had prior therapy for this condition and the records do not demonstrate that the unique skills of a
professional therapist are required to safely and effectively provide treatment, or that the services can be safely
and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has
been authorized two more therapy sessions to transition to a home exercise program. The requested services are
not part of a maintenance 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 the additional visits have not been met. Therefore, we decided that the Plan
does not have to pre-approve eight additional physical therapy visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cold laser therapy/low level therapy for the enrollee.

You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered by Original Medicare.

The Plan must follow Medicare rules. The rules say that low level laser treatment (LLLT)/cold laser therapy is non-covered as a skilled therapy service.

The requested treatment is not covered a skilled therapy service. Based on this information, we decided that Medicare rules for coverage of the therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve cold laser therapy/low level therapy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation visit to be provided by the out-of-network provider.

You asked the Plan to pre-approve the consultation visit to be provided by the out-of-network provider. The Plan denied your request. The Plan says there is not a gap issue and there are in-network providers who can provide the requested service.

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 a consultation visit to be provided by the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor.

You asked the Plan to provide a therapeutic continuous glucose monitor. You say that the enrollee's fingers are getting tender with multiple glucose checks. The Plan denied your request. The Plan says the enrollee is not insulin treated three or more times a day.

The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced above.

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 provide a therapeutic continuous glucose monitor. Our reviewer says that criteria is not met for a therapeutic continuous glucose monitor. Our physician reviewer found in this case, the record indicates that the enrollee uses two insulin injection per day. An after-denial addendum to the record indicates that the enrollee is using sliding scale insulin. The sliding scale parameters are not noted. The record does not credibly indicate that the enrollee is using insulin more than three times a day. The elements of the coverage rule are not satisfied. The requested service cannot be recommended.

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 therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus test strips for the enrollee.

You asked the Plan to pre-approve the test strips. You say that this is medically necessary. The Plan denied your request. The Plan says there is a lack of a diagnosis or the other test strips that have been tried.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered

The plan has other preferred brands that must be tried first. There are no medical records showing a particular clinical reason why the requested brand would be more appropriate. Based on this information, we decided that Medicare rules for coverage of the test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus test strips for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the consultation. You say that you are seeking a second opinion from a neurologist that specializes in spasmodic torticollis. You say the doctor the Plan approved is not the physician that is properly matched to your disease. The Plan denied your request. The Plan says the provider is out of 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 the consultation to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional seven months of rental of a BiPAP machine.

You asked the Plan to pre-approve the additional months. You say that this is medically necessary. The Plan denied your request. The Plan says this was partially approved for continuation of three months.

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 additional months. Our reviewer says that the requested additional months are not considered medically reasonable and necessary in this case. Our physician reviewer found the plan has approved an additional three months of coverage to allow for more time to meet the usage requirements. This is considered reasonable and necessary. The denial of the requested full ten months of coverage is appropriate, because BiPAP will be considered not medically necessary if you are unable to meet the minimum usage requirements (at least 70% of days with at least 4 hours per day) during the 3-month extension.

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 additional months have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional seven months of rental of a BiPAP machine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental implants (D6010).

You asked the Plan to pre-approve the dental implants. You say that the services are medically necessary. The Plan denied your request. The Plan says dental implants are not covered under your 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. Therefore, we decided that the Plan does not have to pre-approve dental implants (D6010).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 18, 2020.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 

We looked at the file and the rules. The claim provided did not include a clinical trial number. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the medical services provided on November 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (E0973, E2361, E1028, K0823).

You asked the Plan to pre-approve the power wheelchair. You say that the power wheelchair is medically necessary. The Plan denied your request. The Plan says the power mobility device is intended for community use and is not covered.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home.

Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (E0973, E2361, E1028, K0823).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the pulp vitality test (D0460), the unspecified preventive service (D1999), the periapical x-ray (D0220) provided on December 15, 2020.

You asked the Plan to pay for the dental services provided on December 15, 2020. You say that you had an infection in your face with cellulitis. You say that this was an urgent visit to see a specialist. You say that you were referred by a plan dentist. You also say that you had to pay out of pocket on the date of service because the provider ended up being out of network. The Plan denied your request. The Plan says comprehensive oral evaluation is not listed as a covered service. The Plan says that pulp vitality test is not listed as a covered service. The Plan says that unspecified preventive service is not listed as a covered service. The Plan also says that periapical x-ray is not listed as a covered service either.

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 the comprehensive oral evaluation (D0150), the pulp vitality test (D0460), the unspecified preventive service (D1999), the periapical x-ray (D0220) provided on December 15, 2020.
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. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of 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 based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF level 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 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.