Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CancerNext gene panel.
You asked the Plan to pre-approve the panel. You say that this is a standard of care, recommended by all oncologic societies, and is relevant to treatment planning for the enrollee as PARP-1 therapy is dependent on this status. The Plan denied your request. The Plan says there is no documentation that indicates a medical condition to warrant a reason to deviate from the Medicare guidelines.
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 panel. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you were diagnosed with ovarian cancer in the fall of 2019. Testing specifically related to your ovarian cancer, for which associated therapies are known, is medically necessary and reasonable. Panel testing, inclusive of testing that is not related to ovarian cancer or for which there are no associated therapies, is not medically necessary or reasonable. The documentation does not support that the requested panel testing is medically necessary or reasonable. 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 panel have not been met. Therefore, we decided that the Plan does not have to pre-approve the CancerNext gene panel.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6539.
You asked the Plan to pre-approve the compression stockings. You say that you need compression stockings because of your leg pain an medical condition. The Plan denied your request. The Plan says compression stockings are non-covered as they are non-reusable supplies.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6539 are non-covered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6539.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to dermatology.
You asked the Plan to pre-approve these services. You say that you aren't able to get care in plan. The Plan
denied your request. The Plan says the referral 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 these services. Our reviewer says that
the referral is not medically necessary. Our physician reviewer found the submitted records show that you have
numerous skin growths called seborrheic keratoses. Care for this condition can be adequately provided by your
primary care physician. A referral to dermatology is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a referral to dermatology.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle.
You asked the Plan to pre-approve the vehicle. You say that this vehicle is not medically necessary for your condition. The Plan denied your request. The Plan says you have difficulty walking.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 vehicle. Our reviewer says that the requested vehicle is not medically reasonable or necessary. Our physician reviewer found there is no notation of an inability to use a lesser device, such as lightweight manual wheelchair, standard manual wheelchair, or use of a walker. Therefore, the request is not medically 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 the vehicle have not been met. Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the skilled nursing facility (SNF) services provided September 7, 2019 to October 6, 2019.
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for the SNF services. The Plan denied your request. The Plan says that the Medicare criteria for continued SNF level of coverage were not met.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case specific records or information was required to substantiate the plans denial. The required information was missing from the original file. A request for medical records was sent to the health plan on April 29, 2020 with a due date of May 6, 2020. As of the date of this letter, the plan has not responded to our request and/or submitted the required information. Therefore, we decided that the Plan has to pay for the skilled nursing facility (SNF) services provided September 7, 2019 to October 6, 2019.
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 compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that this is needed for varicose veins
and a ganglion cyst. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are
noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6530.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bath tub wall rails (E0241).
You asked the Plan to pre-approve the bath tub wall rails. You say that you would like reconsideration because you are about to have surgery. The Plan denied your request. The Plan says this service is not covered by Medicare or the Plan.
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 bath tub wall rails (E0241).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
You asked the Plan to pre-approve the compression stockings. You say that it was advised to use these daily. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pain management to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve pain management. You say that this is the only doctor within 50 miles. You say that you would like approval for these physician services. The Plan denied your request. The Plan says there are in-network providers available for these services. The Plan says that one of these providers is located in Santa Clarita.
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 pain management to be provided by an out of network (OON) provider.
Please contact the Plan for a list of in-network providers available for these services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95885) and nerve conduction studies (95911) provided.
You asked the Plan to pay for needle electromyography and nerve conduction studies. You say that these services were medically necessary. The Plan denied your request. The Plan says the technical report does not contain documentation of these services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure) and 95911 nerve conduction studies; 9-10 studies. 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 pay for needle electromyography and nerve conduction studies. Our reviewer says that these codes are not supported by the records. Our physician reviewer found the records show that the enrollee received intraoperative neurophysiologic monitoring inclusive of somatosensory evoked potentials, motor evoked potentials, electromyographies and train of four monitoring. There is no evidence that the enrollee received nerve conduction studies. Therefore, the billing of CPT 95911 for nerve conduction studies and CPT 95885, which must be performed in conjunction with nerve conductions studies, is not supported. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of needle electromyography and nerve conduction studies have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95885) and nerve conduction studies (95911) provided.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 7 additional physical therapy visits.
You asked the Plan to pre-approve additional physical therapy visits. You say that you need these services to help you to walk again. The Plan denied your request. The Plan says you do not need skilled services beyond what has been approved.
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 additional physical therapy 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 there is no indication prior physical therapy has served to provide sustained, significant improvement in pain or function and there is no indication residual deficits could not be addressed via a home exercise 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 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 7 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core buildup, including any pins when required
(D2950).
You asked the Plan to pre-approve the core buildup. The Plan denied your request. The Plan says this service is
not a benefit covered under Medicare.
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 the
core buildup, including any pins when required (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a generator.
You asked the Plan to pre-approve the generator. You say that a generator is medically necessary. The Plan denied your request. The Plan says generators are not a covered benefit.
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 a generator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an autogenous connective tissue graft procedure (D4273).
You asked the Plan to pre-approve the dental service. You say that the enrollee's tooth # 11 implant has loss of attached gingiva. You say that the gingival margin needs augmentation to protect it from restoration placed or to be placed in the area. You also say that the enrollee is at risk of losing this implant if this treatment is not completed. The Plan denied your request. The Plan says autogenous connective tissue graft procedure is not listed as a covered service. The Plan also says that any service not listed is not 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 autogenous connective tissue graft procedure is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an autogenous connective tissue graft procedure (D4273).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided January 8, 2020.You asked the Plan to pay for the orthosis. You say that please see the attached medical records which prove the medical necessity of the item and process the claim for payment.The Plan denied your request. The Plan says the records provided do not support the service billed.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 pay for the orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, there is no documentation of back pain. There is no documentation of a need to restrict mobility of the trunk, to facilitate healing following an injury to the spine or related soft tissues, to facilitate healing following a surgical procedure on the spine or related soft tissue; or to otherwise support weak spinal muscles and/or a deformed spine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal services to be provided by an out of network dentist.
You asked the Plan to pre-approve the dental services. You say that you have been seeing this dentist since 1995. You say that the closest in network periodontist is more than 45 miles from your home. You also say that due to this, you would like to remain under this dentist's care. The Plan denied your request. The Plan says the dentist in this case is not a network dentist. The Plan also says that dental services you receive out of network are not 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, dental services that you receive out of network are not covered. Therefore, we decided that the Plan does not have to pre-approve periodontal services to be provided by an out of network dentist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral device to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an oral device. You say that the provider you have is not a dentist and a durable medical equipment supplier. The Plan denied your request. The Plan says the in-network provider available is a dentist and supplies oral appliances.
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 an oral device 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 a standard wheelchair replacement.You asked the Plan to pre-approve the replacement. You say that this is needed for a broken wheelchair.The Plan denied your request. The Plan says the wheelchair is less than two years old, and there is no documentation of any functional deficits.The Plan must follow Medicare rules. Medicare rules say that wheelchairs cannot be replaced before five years.The current wheelchair has not reached its reasonable useful lifetime yet. Based on this information, we decided that Medicare rules for coverage of the replacement have not been met.Therefore, we decided that the Plan does not have to pre-approve a standard wheelchair replacement.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extension of the 24 non-emergency transportation trips.
You asked the Plan to pre-approve the extension of the 24 non-emergency transportation trips. You say that your provider feels this service is medically necessary. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because routine transportation beyond 24 one-way trips per year is not covered by the Plan.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of up-to 24 one-way routine trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that routine transportation beyond 24 one-way trips is not covered by the Plan. benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve an extension of the 24 non-emergency transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion consultation to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a second opinion consultation. You say that your doctor recommended you to this facility. The Plan denied your request. The Plan says there are in-network providers available for 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 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 second opinion 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 compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary. The Plan denied your request. The Plan says compression stockings prescribed for the treatment of circulation issues is not a covered benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.