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

We decided that the Plan does not have to pre-approve home ventilator, any type, used with non-invasive interface (CPT code E0466).
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says you will be using the home mechanical ventilator (E0466) in a BiPAP mode and therefore the denial is correct.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 DME. Our physician reviewer found a home ventilator is not medically necessary for this patient. The appropriate treatment for obesity hypoventilation syndrome (OHS) is continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP); Medicare does not cover a ventilator for this diagnosis. The ventilator is to be used as a BiPAP, which is not covered. BiPAP has apparently not been tried at home. 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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve home ventilator, any type, used with non-invasive interface (CPT code E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that this it to protect your skin. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home ventilator, any type, used with non-invasive interface (CPT code E0466).
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 DME. Our physician reviewer found a home ventilator is not medically necessary. The appropriate treatment for obesity hypoventilation syndrome is continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP). Unfortunately, you have been unwilling to use PAP treatment; it is therefore unlikely you will use a home ventilator. The ventilator is to be used as BiPAP, which is not covered by Medicare. Certain BiPAP devices can provide the average volume assured pressure support (AVAPS) mode of support that has been ordered, at less cost. 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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve home ventilator, any type, used with non-invasive interface (CPT code E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bioness L300 Go system, functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified (E0770).
You asked the Plan to pre-approve Bioness L300 Go system. You say that the enrollee will benefit from continued physical therapy and a Bioness unit to help him become more functional. The Plan denied your request. The Plan says this request is not medically necessary because the records show you do not have a non-neurological reason for disuse atrophy, do not have a spinal cord injury and your nerve supply is not intact.
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 Bioness L300 Go system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found coverage of a neuromuscular electrical stimulator is provided only for the treatment of disuse atrophy when the nerve supply to the muscle is intact, including the brain, spinal cord and peripheral nerves. This is not the case for the enrollee, as the nerve supply is not intact. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Bioness L300 Go system have not been met. Therefore, we decided that the Plan does not have to pre-approve Bioness L300 Go system, functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified (E0770).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) and vertical bitewing x-rays (D0277) provided on March 11, 2021, by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that this was a routine dental visit and feel it should be covered in full, as you have not yet met your annual maximum. The Plan denied your request. The Plan says vertical bitewings and adjunctive pre-diagnostic procedures are not covered by your dental benefits. Only services listed in the contract are eligible for coverage up to the Plan's annual dental maximum. In addition, the provider in question is not in the Plan's network, and you may be responsible for any charges that exceed the Plan's maximum payment for the services that are covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) and vertical bitewing x-rays (D0277) provided on March 11, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve acupuncture visits.

You asked the Plan to pre-approve acupuncture. You say that if you do not receive treatment it would be a difficult situation. The Plan denied your request. The Plan says that the denial of authorization for these services is correct, because the records do not indicate that you have chronic low back pain issues.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. 

We looked at the file, the Plan's rules, and Medicare rules. Although this request is not being made for chronic low back pain, your contact with the Plan includes a routine acupuncture benefit for up to 25 routine acupuncture visits per calendar year. The Plan has not provided evidence that this benefit has been exhausted, nor provided any reason that your routine acupuncture benefits should not be covered. Based on this information, we decided that the Plan's rules for coverage of acupuncture have been met. Therefore, we decided that the Plan has to pre-approve acupuncture visits.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CPAP cleaning device.
You asked the Plan to pre-approve the device. You say that you need the component to be cleaned as you use the CPAP machine regularly. You state the machine need you can clean the hose and mask but need the machine itself cleaned. The Plan denied your request. The Plan says Medicare rules say CPAP cleaning devices are hygienic equipment and not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve CPAP cleaning device
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture treatments for digestive issues, pain, low energy, chronic bowel issues and anxiety.
You asked the Plan to pre-approve the acupuncture treatments. You say that you are having sever pain in the left knee, pain in the left elbow, digestive issues, anxiety and sleep issues. You were told that acupuncture would help with these issues and you would like this included as in network benefit. The Plan denied your request. The Plan says the acupuncture treatment requested is not for back pain and there is no documentation indicating that the provider rendering the services is under the supervision of a physician, physician's assistant or nurse practitioner.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the acupuncture treatments is being requested for digestive issues, knee and elbow pain, low energy, chronic bowel issues and anxiety and not for chronic low back pain. Acupuncture for any other condition other than for chronic low back pain is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve acupuncture treatments for digestive issues, pain, low energy, chronic bowel issues and anxiety.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on February 2, 2021.

You asked the Plan to pay for the laboratory services. You say that the documents should be reviewed, and the claim should be processed toward payment. The Plan denied your request. The Plan says Original Medicare is responsible for payment.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on February 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar surgery to be provided by an out-of-network provider.

You asked the Plan to pre-approve lumbar fusion to be performed by an out-of-network neurosurgeon. You say that you were referred to this neurosurgeon by your doctor. The Plan denied your request. The Plan says they have an in-network neurosurgeon who is available.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 lumbar surgery to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on March 17, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for chiropractic services. You say that these services were medically necessary. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that there are in-network providers available to provide these services.

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 chiropractic services provided on March 17, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services provided on June 28, 2021.
You asked the Plan to waive the copayment for lab services. You say that you feel that lab services should be included in annual wellness visits. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $10 copayment for lab services. You received lab services on June 28, 2021. Lab services are not included in annual wellness exams. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment for lab services. Lab services fall 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 copayment for lab services provided on June 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for clinical trial services provided from November 19, 2020, to December 31, 2020.

You asked the Plan to pay for clinical trial services. You say that these services have been covered in the past. The Plan denied your request. The Plan says the necessary information to cover these services has not been received.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 

We looked at the file and Medicare rules. No medical records or other supporting documentation has been submitted to verify the services that were performed on the dates of service at issue. Based on this information, we decided that Medicare rules for coverage of clinical trial services have not been met. Therefore, we decided that the Plan does not have to pay for clinical trial services provided from November 19, 2020, to December 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided on April 13, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary visit. You say that the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 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 the domiciliary visit provided on April 13, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve chiropractic services. You say that you could have filed a lawsuit, but you did not. You say that you would like to continue to see this doctor. The Plan denied your request. The Plan says there are 100 in-network providers available within 20 miles of the member's residency.

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 chiropractic services to be provided by an out-of-network (OON) provider.
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. The Plan denied your request. The Plan says you are receiving appropriate inpatient acute care and do not require transfer.
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 physician reviewer found that in this case, you were admitted to the acute hospital with a ruptured thoracic aortic aneurysm. Following operative intervention, you developed acute hypoxic respiratory failure. You are gradually improving and are receiving necessary care. You continue to receive acute care services, and these have not been denied. The medical record does not indicate that you require services that you are not currently receiving but that would be available at the LTACH facility. Therefore, the elements of the coverage rules are not satisfied.
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 an interspinous process distraction device surgery.

You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). You say that this procedure is covered by Medicare. The Plan denied your request. The Plan says Medical studies haven't proven that the device is helpful for treatment of the enrollee's 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 insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous process distraction devices remain experimental. More research is needed to show safety and efficacy of the devices. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous process distraction device surgery.