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

We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).

You asked the Plan to pre-approve Vertiflex. You say that this treatment is considered safe and effective and is medically necessary for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there are not enough studies on Vertiflex to show it is safe and effective.

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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilling nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursing or therapy services are not required on a "daily basis" or as a practical matter on an inpatient basis, in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve paravertebral facet joint injections.

You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied your request. The Plan says there is evidence of a radicular component of the pain.

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 injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the right sided pain is radicular in nature consistent with spinal stenosis as shown by MRI at the L3-L4 and L4-L5 levels. The presence of radiculopathy does not satisfy the coverage criteria.

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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve paravertebral facet joint injections.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve esophagogastroduodenoscopy to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve esophagogastroduodenoscopy to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have been met.
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 esophagogastroduodenoscopy to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the abdomen and pelvis (74177) provided on November 21, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for each Medicare-covered diagnostic radiology and complex imaging service. You have been asked to pay a $200 copayment for the Medicare-covered diagnostic imaging service provided. 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 the computed tomography (CT) scan of the abdomen and pelvis (74177) provided on November 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve left knee genicular radiofrequency ablation 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 this is considered experimental and 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 injection. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found this is an experimental/investigational procedure that is the subject of on-going clinical trials. Therefore,
the request is considered 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 injection have not been met. Therefore, we decided that the Plan does not
have to pre-approve left knee genicular radiofrequency ablation for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 the monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee is not on insulin and checks her sugar twice daily. The elements of the local coverage determination criteria are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve low back injections.
You asked the Plan to pre-approve low back injections. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 low back injections. 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 other clear pain generators, i.e. 3 extruded discs. Therefore, the coverage criteria are not met, and the request is considered 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 low back injections have not been met. Therefore, we decided that the Plan does not have to pre-approve low back injections.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) care after April 18, 2021.

You asked the Plan to pre-approve SNF care. You say that you want to continue therapy and do not have a safe discharge plan.The Plan denied your request. The Plan says the denial of authorization for continued SNF care after April 18, 2021 is correct.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) care after April 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Lidocaine, Niacinamide, and Sodium Bicarbonate.

You asked the Plan to pre-approve treatment with Lidocaine, Niacinamide, and Sodium Bicarbonate. You say that this is necessary to treat the enrollee's pain. The Plan denied your request. The Plan says this is experimental.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 treatment with Lidocaine, Niacinamide, and Sodium Bicarbonate. Our reviewer says that the requested use of these medications is not supported. Our physician reviewer found this is an experimental/investigational use of this combination of medications. It 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 treatment with Lidocaine, Niacinamide, and Sodium Bicarbonate have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Lidocaine, Niacinamide, and Sodium Bicarbonate.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI)
provided on September 10, 2020.

You asked the Plan to waive the copayment for the MRI. You say that you feel you should not be responsible
for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your
request. The Plan says you received an MRI on the date of service at issue in this appeal. The Plan says that the
correct copayment has applied per your contract with the Plan.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200
copayment for Medicare-covered diagnostic radiology services provided in an outpatient hospital setting.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an MRI in an
outpatient hospital setting on September 10, 2020. You have been asked to pay a $200 copayment for the MRI.
The MRI falls within the Outpatient diagnostic tests 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 the magnetic resonance imaging (MRI) provided on September 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal injections 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 there have been no medial branch blocks.

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 injection. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found it is inappropriate to repeat injections that were "minimally effective." This request 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 injection have not been met. Therefore, we decided that the Plan does not
have to pre-approve spinal injections for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a duplex scan.

You asked the Plan to pre-approve a duplex scan. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that international consensus documents previously recommended 0.5 seconds as a cutoff value for all veins to use for lower limb venous incompetence.

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 duplex scan. Our reviewer says that the services are medically necessary. Our physician reviewer found the request for the battery of venous duplex scans is very reasonable to follow the success or failure of the left iliac venous stent and the evaluation of the deep and superficial venous system. Also, since the stent is close to the right iliac artery the follow-up of the aorta and the iliac and femoral arteries makes sense. The disease entity is rare and the stent therapy as well as the underlying predisposition to dangerous downstream clots provide valid indications for the requested studies.

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 duplex scan have been met. Therefore, we decided that the Plan has to pre-approve a duplex scan.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the replacement of a broken tooth (D5640) provided on December 21, 2020.
You asked the Plan to pay for the dental services. You say that your dentures have been nothing but bothersome. You say that the dentures are of poor quality and break easily. You say that it is quite difficult for you to cover the charge. You also say that you are worried that the dentures will continue to break. The Plan denied your request. The Plan says the replacement of a broken tooth is not a covered service.
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 replacement of a broken tooth (D5640) provided on December 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services provided on January 6, 2021. 

You asked the Plan to waive the copayment for the laboratory services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received lab services on the date of service at issue in this appeal. The Plan confirmed with your provider that this was an additional laboratory test sent out to the lab. The Plan says that the correct copayment has applied per your contract with the Plan.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 copayment for Medicare-covered lab tests.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received laboratory services on January 6, 2021 that your provider sent to an outside lab. You have been asked to pay a $5 copayment for the laboratory services. The laboratory services fall within the Outpatient diagnostic tests 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 the laboratory services provided on January 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth visit (Q3014) provided on
November 11, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45
copayment for physician services provided by an in-network specialist.
You have been asked to pay a $26.65 copayment for the telehealth visit provided by an in-network specialist.
This amount is the Plan allowed amount which is less than the applicable copayment for this service. 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 the telehealth visit (Q3014) provided on November 11,
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397)
provided September 8, 2020.
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items provided were
medically necessary. The Plan denied your request. The Plan says there was no established relationship
between the provider and the member.
The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to
the criteria listed 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 pay for the knee orthosis and suspension sleeve. Our
reviewer says that the requested items were not medically reasonable and necessary. Our physician reviewer
found in this case there is no recent injury or surgery to the knee. Furthermore, knee instability is subjectively
described without credible evidence of objective findings. The elements of the local coverage determination are
not satisfied. In the absence of coverage for the base orthosis, the elements of the coverage for the suspension
sleeve are not satisfied.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the knee orthosis and suspension sleeve have not been met. Therefore, we
decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397)
provided September 8, 2020.