Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Synvisc-One.
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 that the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has right knee pain for an unspecified number of months with "popping and cracking," medial joint line tenderness and a history of multiple sports injuries. An x-ray showed no joint space narrowing but a magnetic resonance scan showed a 5 millimeter articular cartilage defect. She has failed treatment with analgesics and intra-articular corticosteroid injection. The physical exam is consistent with osteoarthritis. Although the plain x-ray was not consistent with osteoarthritis, magnetic resonance scanning has been reported in the medical literature to identify osteoarthritis at earlier stages of disease before plain x-ray changes become apparent. The Synvisc-One is safe and effective and reasonable and medically necessary at this time. 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 been met. Therefore, we decided that the Plan has to pre-approve Synvisc-One.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital services provided on September 13, 2019, through September 15, 2019.
You asked the Plan to pay for the hospital services. You say that you would like reconsideration because the claim was not filed in a timely manner due to COVID-19. The Plan denied your request. The Plan says Medicare denies a claim if it is not received by the plan within 12 months or 1 calendar year from the date when the services were rendered.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the hospital services was not filed until October 19, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the hospital services provided on September 13, 2019, through September 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided on September 30, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem.
We find that the testing services are not supported in the medical record. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on September 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walker holder.
You asked the Plan to pre-approve a walker holder. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is 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 walker holder.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services.
You asked the Plan to pre-approve chiropractic services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. 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 chiropractic services. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found you have undergone ongoing chiropractic treatment. Medicare guidelines state that maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment become supportive rather than corrective in nature, the treatment is then considered maintenance therapy. You state that you are requesting coverage for chiropractic maintenance as you have had three back surgeries and have a disk and cage in your back. The one chart note submitted, dated March 2, 2021, reveals that you did not have any complaints other than you would like to maintain where you are at in her current chiropractic care schedule. Therefore, the requested services are for maintenance therapy, which is not supported or allowed per Medicare guidelines. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of chiropractic services have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging.
You asked the Plan to pre-approve myocardial perfusion imaging. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this testing is correct, because this testing is not medically necessary.
The Plan follows Medicare rules. Medicare rules state that cardiovascular nuclear imaging such as myocardial perfusion imaging may be covered for certain specific indications. 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 myocardial perfusion imaging. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested testing. Our physician reviewer found the enrollee reported a 3-month history of shortness of breath, both with rest and exertion. The enrollee denies chest pain/pressure. The enrollee's inhaler was changed a few weeks prior, and he noted significant improvement in his breathing. A nuclear stress test was ordered to evaluate for ischemic changes. The documentation does not support that the enrollee has a covered indication for myocardial perfusion imaging. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of myocardial perfusion imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.

You asked the Plan to pre-approve radiofrequency ablation. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low back pain. The enrollee has tried physical therapy and medication management. The requested service is considered an experimental/ investigational procedure due to the wide variation in efficacy in the peer reviewed literature. Therefore, the enrollee does not meet criteria for the requested 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pegfilgrastim injections (J2505).
You asked the Plan to pre-approve pegfilgrastim injections. You say that this was requested appropriately. The Plan denied your request. The Plan says coverage of this medication is the responsibility of Original Medicare.
The Plan must follow Medicare rules. Medicare rules say that Original Medicare covers the routine costs of qualifying clinical trials for all Medicare enrollees, including those enrolled in Medicare Advantage (MA) plans, as well as reasonable and necessary items and services used to diagnose and treat complications arising from participating in qualifying clinical trials. We looked at the file and Medicare rules. The record shows that the requested drug is being used in a clinical trial. Coverage of clinical trial costs is the responsibility of Original Medicare. Based on this information, we decided that Medicare rules for coverage of pegfilgrastim injections have not been met. Therefore, we decided that the Plan does not have to pre-approve pegfilgrastim injections (J2505).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement prosthesis and socket except for K3 prosthesis.
You asked the Plan to pre-approve replacement prosthesis and socket except for K3 prosthesis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that replacement prosthesis and socket except for K3 prosthesis are only covered for certain indications. 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 replacement prosthesis and socket except for K3 prosthesis. Our reviewer says that the documentation does not support that the requested items are medically reasonable or necessary. Our physician reviewer found the enrollee has a prosthetic from 2018 and has not worn it in over a year due to it not fitting. There is no evidence of long-term effectiveness and safety in the literature for the use of the RevoFit. In addition, the documentation shows that the additional components requested appear to exceed the enrollee's medical need and are not medically necessary. Therefore, the enrollee does not meet criteria for the requested items.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of replacement prosthesis and socket except for K3 prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve replacement prosthesis and socket except for K3 prosthesis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services for the enrollee coded as D6740 and D6240.
You asked the Plan to pre-approve these dental services. You say that these dental services are medically necessary. The Plan denied your request. The Plan says these dental codes are not covered by the Plan. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct dental benefit.
The Plan is correct in this case. Medicare does not cover dental services. 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 services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental services for the enrollee coded as D6740 and D6240.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Uloric.
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 self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Uloric.
Benefits for these services 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 pay for the two endosteal implants (D6010 x2) provided on October
8, 2020.
You asked the Plan to pay for the endosteal implants. You say that you were advised that this was a medical
issue, and believe it should be covered. The Plan denied your request. The Plan says this service is not a
covered benefit under your dental plan.
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 two
endosteal implants (D6010 x2) provided on October 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 based on the documentation provided, the health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vertebral augmentation procedure, kyphoplasty of L1
vertebrae (22514).
You asked the Plan to pre-approve the kyphoplasty. You say that fracture had persistent edema on MRI on
12/14/20 suggesting persistent fracture which was less than 6 weeks from most recent appointment. The Plan
denied your request. The Plan says the enrollee's condition does not meet the criteria under the LCD.
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 kyphoplasty. 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 enrollee was being treated for wedge compression fracture of first lumbar
vertebra. Diagnostic studies confirm the presence of a subacute, 50% burst fracture of the superior endplate of
L1 with minimal retropulsion. However, enrollee notes she fell down the stairs in July, 2020. The CT scan
noted from 7/10/20 demonstrated a mild L1 superior endplate fracture. Guidelines do not support this
procedure for vertebral compression fractures outside of the acute (<6 weeks) or subacute (6-12 weeks) stage.
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity
of this request as an exception. Therefore, the request for kyphoplasty of L1 vertebrae is not medically
reasonable or 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 kyphoplasty have not been met. Therefore, we decided that the Plan does
not have to pre-approve vertebral augmentation procedure, kyphoplasty of L1 vertebrae (22514).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three additional spinal manipulation treatments (98941).

You asked the Plan to pre-approve three additional spinal manipulation treatments. You say that these services are necessary because you are in severe pain and are trying to avoid surgery. The Plan denied your request. The Plan says the requested services are non-covered maintenance therapy.

The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care.

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 three additional spinal manipulation treatments. Our reviewer says that the requested chiropractic treatments are maintenance treatments and are not supported. Our physician reviewer found you have undergone chiropractic treatments. All objective findings show well contained subluxations that are unchanged since the last visit. All assessments reveal that your condition is stable at this time. You exhibit the same or similar complaints throughout care, with the same or similar nondescript findings, the same or similar assessment, and the same or similar treatment rendered. There is no evidence that any clinical improvement has occurred or that any treatments have provided any benefit, with no evidence that further clinical improvement can reasonably be expected from continuous ongoing care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of three additional spinal manipulation treatments have not been met. Therefore, we decided that the Plan does not have to pre-approve three additional spinal manipulation treatments (98941).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Carboplatin, Paclitaxel and Cetuximab.

You asked the Plan to pre-approve Carboplatin, Paclitaxel and Cetuximab. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drugs are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Carboplatin, Paclitaxel and Cetuximab. Our reviewer says that the documentation does not support that the requested drugs are medically reasonable or necessary. Our physician reviewer found the enrollee has basal cell carcinoma of the back with mets to the right axilla. The documentation does not support that the requested drugs are FDA approved for the enrollee's diagnosis. The documentation does not support that requested drugs are supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the enrollee does not meet criteria for the requested drugs.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Carboplatin, Paclitaxel and Cetuximab have not been met. Therefore, we decided that the Plan does not have to pre-approve Carboplatin, Paclitaxel and Cetuximab.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest.
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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has emphysema with a pulmonary nodule of five millimeters found on imaging. The nodule was unchanged on a repeat CT scan in 2020. There are no new symptoms or evidence to support the requested CT scan of the chest. The services are 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 computed tomography (CT) scan of the chest.