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

We decided that the Plan does not have to pre-approve an interspinous spacer device.

You asked the Plan to pre-approve the requested services. You say that the treatment is supported by the clinical benefits. The Plan denied your request. The Plan says the enrollee does not meet the requirements for moderate spinal stenosis.

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 requested services. Our physician reviewer found that in this case, the enrollee indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The record indicates that the enrollee has had that does not demonstrate moderate central canal or foraminal stenosis. 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the spine surgery (22899) and destruction of intraosseous basivertebral nerve (C9752 and C9753).

You asked the Plan to pre-approve the spine surgery (22899) and destruction of intraosseous basivertebral nerve (C9752 and C9753). You say that the member's pain is disabling, affects his qualify of life and has been of long-term duration. You say that the member has failed all non-operative treatment options and the Intracept procedure is truly the only solution. The Plan denied your request. The Plan says the Intracept procedure is not covered because it is considered experimental/investigational.

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 spine surgery (22899) and destruction of intraosseous basivertebral nerve (C9752 and C9753). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and efficacy. 

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 spine surgery (22899) and destruction of intraosseous basivertebral nerve (C9752 and C9753) have not been met. Therefore, we decided that the Plan does not have to pre-approve the spine surgery (22899) and destruction of intraosseous basivertebral nerve (C9752 and C9753).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six podiatry office visits and treatment to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve six podiatry office visits and treatment. You say that the enrollee is dependent on care staff to transport her within the assisted living facility, however, there is no staff available to accompany her to outside appointments. You also say that you are living in a different state, and you are dependent on wheelchair accessible taxi transport to get the enrollee to appointments when you are with visiting her. You also say traveling is you have been left stranded the past three times you have tried to arrange taxi services and you have cannot begin to talk of the hardships you endure trying to get her toenails clipped. The Plan denied your request. The Plan says the provider you requested is not the network and the provider did not provide records that show that the enrollee's medical needs cannot be met 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 six podiatry office visits and treatment 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 a crown - porcelain fused to high noble metal (D2750).
You asked the Plan to pre-approve a crown. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefits.
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 crown - porcelain fused to high noble metal (D2750).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty power operated vehicle (POV) and attachments.
You asked the Plan to pre-approve a heavy duty POV and attachments. You say that these items are medically necessary. The Plan denied your request. The Plan says that the physician office notes do not show mobility deficits impairing MRADLs.
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 a heavy duty POV and attachments. Our reviewer says that a heavy duty POV and attachments are not medically reasonable and necessary. The documentation does not support that you have a mobility deficit that impairs MRADLs in the home and that this mobility limitation is not ameliorated by a walker, cane or manual wheelchair. While you may have the
cognition to safely operate the power scooter the documentation does not reveal a home assessment to support that the requested device will be able to safely maneuver in the home and access rooms for MRADL participation. The documentation does not support that the POV will significantly improve your ability to participate in MRADLs and you will use it in the home. Our physician reviewer found that your condition does not meet criteria for coverage of these services. 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 heavy duty POV and attachments have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty power operated vehicle (POV) and attachments.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.
You asked the Plan to pre-approve an Intracept procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.
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 an Intracept procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental. More research is needed to show it is safe and effective. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) lower extremity, knee (73700).

You asked the Plan to pre-approve the CT scan. You say that review the evidence supporting the use of pre-operative CT's when required for performing Mako robotic assisted knee arthroplasty procedures. You request the Plan reverse its decision and approve the prior authorization. The Plan denied your request. The Plan says the records do not support that the CT scan is medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

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 CT scan. 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, the record indicates that the enrollee requires a knee replacement. The record indicates that the provider is planning a robotic knee replacement. The provided records do not indicate the medical necessity or reasonableness, as defined by Medicare rules, of the requested service. Therefore, the requested CT scan to prepare for the knee replacement is also not medically necessary or reasonable, as defined by Medicare rules. 

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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) lower extremity, knee (73700).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cardiology office visit provided on May 10, 2021.

You asked the Plan to waive the copayment for specialist visit. You say that you do not have any money left to pay this amount. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 $35 copayment for in-network specialist visit.

You have been asked to pay $35 copayment for specialist visit. Specialist visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a cardiology office visit provided on May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve scaling in moderate or severe gingival inflammation (D4346) to be provided by a participating provider.

You asked the Plan to pre-approve scaling in moderate or severe gingival inflammation. You say that you would like the Plan to approve the requested dental services. The Plan denied your request. The Plan says D4346 is not a covered dental 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 scaling in moderate or severe gingival inflammation (D4346) to be provided by a participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.

You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the records received show that your condition has improved, and you are no longer a threat to yourself or others.

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 pre-approve inpatient psychiatric hospital services.

Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is not expected you will improve in a reasonable period of time as you do not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. You were compliant with treatment while not showing any acute threats to safety. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as you do not have dangerousness to self or others and were compliant with your treatment. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient psychiatric hospital services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the services are custodial in nature.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 requested services. Our physician reviewer found that in this case, the documentation does not support that you require additional skilled nursing services or skilled rehab services to provide treatment that is medically necessary. You do not require additional skilled nursing or rehab services to provide treatment to improve your condition, perform a maintenance program to maintain your condition or prevent deterioration. You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Therefore, the requested home health services are 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the member's medical conditions are stable and there are no complex nursing or rehabilitation needs. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Specifically, medically necessary services can be obtained in a lower level of care. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an outpatient office visit (99204) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve an office visit. You say that please review for medical necessity. 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. The Plan has approved a Neurology consult with an in-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 an outpatient office visit (99204) to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ambulance transport to see your urologist for a procedure.
You asked the Plan to pre-approve the ambulance transport. The Plan denied your request. The Plan says you are not on life support and there is no emergent need for ambulance transport.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pre-approve are ambulance transport services to a doctor's office.
Therefore, we decided that the Plan does not have to pre-approve ambulance transport to see your urologist for a procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sedation (D9239) to be provided by a participating
provider.
You asked the Plan to pre-approve sedation. You say that you would like the Plan to approve and pay for these
dental services. The Plan denied your request. The Plan says D9239 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
sedation (D9239) to be provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nephrologist services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve nephrologist services. You say that the participating provider does not have availability anytime soon and the out-of-network provider has the best ratings in your area. The Plan denied your request. The Plan says according to the plan benefits, you must use network providers to get medical care and services where there are network providers available. The Plan also says that from the records they received, no medical need is shown as to why the enrollee cannot get this service from a provider within the Plan.
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 nephrologist services 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 a custom fabricated abutment - includes placement (D6057) and implant supported crown - porcelain fused to high noble alloys (D6066).
You asked the Plan to pre-approve an abutment and abutment supported crown. You say that it does not make sense that a crown on an abutment is covered differently than a crown on a tooth. The Plan denied your request. The Plan says these services are not covered under the enrollee's benefits.
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 custom fabricated abutment - includes placement (D6057) and implant supported crown - porcelain fused to high noble alloys (D6066).
Your complaint about the exclusion of implant related services from the Plan's benefits is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.