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

 We decided that the Plan does not have to pre-approve non-emergent transport, taxi, (A0100) 2 to 4 time per week.  You asked the Plan to pre-approve non-emergent taxi transport. You say that it is very difficult for you to get around. You say that you do not have any way to get around. You also say that you can only get in and out of certain vehicles. The Plan denied your request. The Plan says non-emergency taxi transportation is not covered by Medicare or the Plan.  The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule.   We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of non-emergent taxi transport have not been met. Specifically, non-emergency taxi transportation is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve non-emergent transport, taxi, (A0100) 2 to 4 time per week.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a referral to an out-of-network dermatologist.  You asked the Plan to pre-approve these services. You say that there are no network providers with the necessary expertise. The Plan denied your request. The Plan says the services are available from network providers.  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. The Plan confirmed that the network providers are qualified to evaluate and treat your condition. 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 dermatologist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections (64494, 64495).

You asked the Plan to pre-approve facet joint injections. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has not failed conservative treatment.

The Plan must follow Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis and treatment of chronic pain when the pain has been present for minimum of 3 months with documented failure to respond to noninvasive conservative management. 

We looked at the file and Medicare rules. The records show that the enrollee has not tried physical therapy and that the pain has been responsive to medication. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections (64494, 64495).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Vimpat.  You asked the Plan to pre-approve Vimpat. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vimpat.   Benefits for Vimpat may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft (D7953) to be provided by a participating provider.

You asked the Plan to pre-approve a bone replacement graft. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the requested dental work 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 a bone replacement graft (D7953) to be provided by a participating provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve occupational therapy (OT) visits (97110, 97530, 97535) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve out-of-network OT services. You say that this is the closest occupational therapy facility to the enrollee, and these services are medically necessary. The Plan denied your request. The Plan says out-of-network care is only covered in certain limited circumstances. The requested care is not urgent or emergent, and there are in-network providers who can perform these services within a reasonable distance from the enrollee.  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 occupational therapy (OT) visits (97110, 97530, 97535) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive eye examination (92014) provided January 27, 2021  

You asked the Plan to pay for the vision services. You say that this is a routine medical exam and you have never required prior authorization in the past. The Plan follows Medicare guidelines and Medicare does not require prior authorization for this CPT code. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  

Medicare 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 covers these services when rendered by an in-network provider.  

We looked at the file and the Plan's rules. Enrollee's must receive their medical services from an in-network provider. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive eye examination (92014) provided January 27, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a MyoPro Motion G orthosis.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the records document a right shoulder subluxation that may be a contraindication to use of the MyoPro device. Furthermore, current clinical guidelines state the device has unproven benefit in the home environment. The services are therefore 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 MyoPro Motion G orthosis.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Jardiance tablet, 10 mg.  

You asked the Plan to pre-approve Jardiance tablet. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.  

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Jardiance tablet, 10 mg.   

Benefits for Jardiance tablet may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 15 physical therapy (PT) visits to be rendered by an out-of-network (OON) provider.  You asked the Plan to pre-approve the PT visits. You say that you are the enrollee's transportation, and if you could both get therapy on the same schedule it would greatly assist your household and be able to get the enrollee to the therapy appointments, she needs to improve her mobility and balance. The Plan denied your request. The Plan says the enrollee can get the care she needs within the Plan's 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 15 physical therapy (PT) visits to be rendered by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implant placement (D6010) for teeth # 4, 7, 10, 13, 22, and 27.

You asked the Plan to pre-approve implant placements. You say that you need at least 2 of these to be approved. You say that you have having problems using your dentures. You say that without these implants, you cannot use your dentures. You also say that you cannot talk properly. The Plan denied your request. The Plan says implants and all related services 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, the requested implant placements are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve implant placement (D6010) for teeth # 4, 7, 10, 13, 22, and 27.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve hydroxychlor tablet, 200 mg.  You asked the Plan to pre-approve hydroxychlor tablet. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve hydroxychlor tablet, 200 mg.   Benefits for hydroxychlor tablet may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve OON physical therapy services. You say that the enrollee was approved to see the requested provider in the past. The Plan denied your request. The Plan says this is available in-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a referral to an out-of-network neurologist.  You asked the Plan to pre-approve these services. You say that you were told by this provider's staff that they are in-network. The Plan denied your request. The Plan says the services are available from network providers.  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 neurologist.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Flecainide tablets.
  
You asked the Plan to pre-approve Flecainide tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Flecainide tablets are not covered under the enrollee's Medicare Part B benefit.
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Flecainide tablets.
   
Benefits for Flecainide tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a quantitative calcium scoring procedure (75571).  You asked the Plan to pre-approve quantitative calcium scoring. You say that the requested service is a medical necessity for you. The Plan denied your request. The Plan says the requested service is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that quantitative calcium scoring is not a covered service. Based on this information, we decided that Medicare rules for coverage of quantitative calcium scoring have not been met. Therefore, we decided that the Plan does not have to pre-approve a quantitative calcium scoring procedure (75571).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of Orthovisc in the setting of hip arthritis have not been demonstrated in the peer-reviewed literature.

The Plan must follow Medicare rules. The rules say that hyaluronan injection are only covered for treatment of knee osteoarthritis. 

This request is being made for treatment of hip arthritis. This is not a covered indication for the requested type of injection. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc injection for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Xhance nasal spray. 
 
You asked the Plan to pre-approve Xhance. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xhance nasal spray.   Benefits for Xhance may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to approve inpatient psychiatric services beginning January 12, 2022.  You asked the Plan to approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   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 approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on December 22, 2021 with recurrent severe major depressive disorder without psychotic features. Based on the submitted records, it is not expected he would improve in a reasonable period of time beyond the dates in question, as he is not showing dangerousness to self or others. He has no auditory or visual hallucinations and no aggressive behaviors. He is cooperative and compliant with medication. He has no suicidal or homicidal ideation. It does not appear that active treatment was taking place beyond the dates in question. Continued psychiatric services are not reasonable or medically necessary based on the submitted records.  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 approve inpatient psychiatric services beginning January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network neurologist.

You asked the Plan to pre-approve these services. You say that the network providers do not have a headache specialist. The Plan denied your request. The Plan says the services are available from network providers.

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. The Plan confirmed that the providers are qualified to evaluate and treat your diagnosis of headaches. 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 neurologist.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an out-of-network referral to an interventional cardiologist for Mitral Clip Surgery.

You asked the Plan to pre-approve an out-of-network referral. You say that the Plan has no in-network providers available to the enrollee that can perform the surgery the enrollee needs. The Plan denied your request. The Plan says that there are in-network providers available to the enrollee.

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, the file shows the enrollee needs surgery for severe mitral regurgitation repair. An out-of-network referral request was previously requested; however, denied by the Plan and the Plan referred the enrollee to an in-network specialist. This in-network specialist determined that the enrollee needs to have Mitral Clip surgery and says there are no in-network providers available to the enrollee that can perform this procedure. The Plan's in-network provider requested an out-of-network referral to an interventional cardiologist who can perform this type of procedure. We sent a request to the Plan to provide a list of in-network providers that could perform this type of surgery. It was determined after further research, the recommended in-network providers do not show that they perform the type of surgery the Plan's contracted provider believes the enrollee needs. We find that the Plan has not provided sufficient evidence showing that they have in-network providers available to the enrollee to meet the enrollee's medical needs. Therefore, we decided that the Plan has to pre-approve an out-of-network referral to an interventional cardiologist for Mitral Clip Surgery.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.