Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve blocks for the enrollee. You asked the Plan to pre-approve these services. You say that the services are medically necessary. 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 enrollee has knee osteoarthritis. She has had intra-articular knee injections with steroids but the relief was only one month. She had a Synvisc injection without benefit. The requested genicular nerve blocks are considered experimental/investigational in nature and are the subject of ongoing clinical trials. The enrollee is not in a clinical trial. 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 genicular nerve blocks for the enrollee. The Plan references Local Coverage Determination (LCD) L35456in their determination; however, this LCD is not binding for the services at issue and was not used in the MAXIMUS determination.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an aqua-colored cane to be provided by out of network provider. You asked the Plan to pre-approve an aqua-colored cane. You say that you have fallen and you need a cane to walk. The Plan denied your request. The Plan says in-network supplier can provide a standard silver or gray cane.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 pre-approved care.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.The rules say that services that are not medically necessary are not covered. Colored versions of a cane are not medically necessary. Therefore, we decided that the Plan does not have to pre-approve an aqua-colored cane to be provided by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cleanings under your medical benefit to be provided by your dental provider. You asked the Plan to pre-approve the cleanings. You say that because of radiation therapy, your upper jaw and lower jaw osteoradionecrosis. You also say that in order to keep your radiation damaged upper teeth, you were told you must have an exam and cleaning every 3 months.The Plan denied your request. The Plan says your medical benefits do not cover routine dental services.Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve cleanings under your medical benefit to be provided by your dental provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio injections. You asked the Plan to pre-approve Entyvio. You say that the Entyviois medically necessary for treatment of the enrollee's Crohn's disease. The Plan denied your request. The Plan says the Entyvio is 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 Entyvio. Our reviewer says that coverage criteria has not been met. Our physician reviewer found while Entyvio is indicated in treatment of Crohn's disease patients who are refractory to conventional medical management, the enrollee's records fail to demonstrate this diagnosis in her case nor her circumstance. Indeed, the patient had no leukocytosis at the time of drug initiation, nor do her records support the medical necessity for subsequent Entyvio dose optimization.We looked at this physician's review,the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approveEntyvio injections.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay fora panniculectomy (15830).You asked the Plan to pay fora panniculectomy. You say that you need this surgery due to bleeding and odor.The Plan denied your request. The Plan says this is cosmetic.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for a panniculectomy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found although you satisfy the above criteria for panniculectomy, the Plastic Surgery documentation notes that you are a poor candidate for panniculectomy given your current level of obesity and history of keloids. Therefore, if the surgeon who would be performing the surgery does not feel that the procedure is safe, then the procedure should not be considered medically necessary at this point.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 panniculectomy havenot been met.Therefore, we decided that the Plan does not have to pay fora panniculectomy (15830).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry with electrocardiographic recording (93228 and 93229).You asked the Plan to pre-approve mobile outpatient cardiac telemetry. You say that this service is medically necessary. The Plan denied your request. The Plan says the documentation fails to indicate that the member has had a symptomatic transient or paroxysmal dysrhythmia.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 mobile outpatient cardiac telemetry. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found off-line analysis of a patient-activated or auto-triggered event recorder should be sufficient in the identification of dysrhythmias without jeopardizing the member's safety. The use of real-time mobile wearable cardiovascular telemetry through exceeds the member's medical needs at this time, in my opinion.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of mobile outpatient cardiac telemetry have not been met. Therefore, we decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry with electrocardiographic recording (93228 and 93229).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation of the lateral sacral branches for the enrollee.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that lumbar injections are only covered under certain medical 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 the requested services. Our physician reviewer found that the enrollee has chronic low back pain and sacroiliac joint pain. He is status post L4-L5 laminectomy. He had diagnostic lateral sacral branches and achieved 80% pain relief. The request is for RFA of the lateral sacral branches. This is an experimental/ investigational procedure. The reported efficacy of the procedure varies widely due to differences in technique. Therefore, the requested procedure is deemed 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of the lateral sacral branches for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
You asked the Plan to pre-approve the compression stockings. You say that you require the stockings for swelling in your knee that occurred after a fall. The Plan denied your request. The Plan says these stockings are examples of wound care items which are non-covered under the surgical dressing benefit because they do not meet the statutory definition of a dressing.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are non-covered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadditional outpatient physical therapy visits.You asked the Planto pre-approvethe additional visits. You say that this is medically necessary.The Plandenied your request. The Plansaysadditional physical therapy services do not meet medical necessity criteria.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific and effective therapy for the patient's condition. You have had extensive therapy and your pain level is unchanged. You have had a 5% improvement from 9/4/19. Your records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. You should be competent in a home exercise program at this point. The specialized skill,knowledge and judgment of a qualified therapist are not required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.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 additional visits have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadditional outpatient physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Inspire Upper Airway Stimulation (UAS) device (0466T and 64568).You asked the Plan to pre-approvethe Inspire UAS device. You say that you would like the plan to reconsider theirdenial.The Plan denied your request. The Plan says the Inspire UAS device is not covered by Medicare or the plan.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The Inspire Upper Airway Stimulation (UAS) device (also known as a hypoglossal nerve stimulator) with procedure code 0466T is currently excluded from Medicare coverage. Based on this information, we decided that Medicare rules for coverage of the Inspire UAS device have not been met.Therefore, we decided that the Plan does not have to pre-approvethe Inspire Upper Airway Stimulation (UAS) device (0466T and 64568).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.You asked the Plan to pre-approve the compression stockings. You say that your doctor measured you for lymphedema and you need them.The Plan denied your request. The Plan says the compression stockings are not covered.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha 140 MF/MI Sureclick.You asked the Plan to pre-approve Repatha. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says Repatha is 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 Repatha 140 MF/MI Sureclick.Benefits for Repatha may be available under Medicare Part D.Contactthe 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 general anesthesia.You asked the Plan to pre-approve general anesthesia. You say that you have never had an extraction without also having anesthesia. You say that you are appealing the denial.The Plan denied your request. The Plan says these are not covered 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 general anesthesia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea wheelchair lift for a vehicle and a wheelchair ramp for home access to be provided by the provider.You asked the Plan to pre-approvea wheelchair lift and a ramp. You say that the enrollee needs assistance with a power mobility device for getting it in and out of a vehicle otherwise it would remain in the vehicle.The Plan denied your request. The Plan says Medicare does not cover wheelchair lifts for vehicles or ramps for homes.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The itemsat issue in this appeal arefor use outside of the home. Although theseitemsmay be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Medicare does not cover home modifications.Therefore, we decided that the Plan does not have to pre-approvea wheelchair lift for a vehicle ora wheelchair ramp for home access
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pneumatic compression device (E0652) with full arm sleeve (E0668).You asked the Plan to pre-approvea pneumatic compression device and full arm sleeve. You say that the enrollee would benefit from an updated pump since her current one is over 10 years old. She would benefit from the Flexitouch for continued lymphedema control and to improve function.The Plan denied your request. The Plan says the LCD criteria has not been met as lymphedema does not extend to the trunk, chest or abdomen.The Plan follows Medicarerules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider. You asked the Plan to pre-approve these services. You say that the provider is no longer contracted but previous referrals have been approved.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 pre-approved care.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 the medical services to be provided by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve afoot orthotics fitting service.You asked the Plan to pre-approve afoot orthotics fitting. You say that you need orthotics to relieve your foot pain.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.A foot orthotics fitting service is unnecessary since you do not meet criteria for orthotics.Therefore, we decided that the Plan does not have to pre-approve afoot orthotics fitting service.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Gastro Specialist visit (99205) with contracted tertiary provider.
You asked the Plan to pre-approve the specialist visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the requested services can be provided by a non-tertiary provider.
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 specialist visit. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record does not show the need for a tertiary level of care. Your care can be adequately rendered by the non-tertiary providers approved by the Plan. 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 specialist visit have not been met. Therefore, we decided that the Plan does not have to pre-approve a Gastro Specialist visit (99205) with contracted tertiary provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional non-emergent transportation. You asked the Plan to provide additional non-emergent transportation. You say that you would like the Plan to approve extra trips so that you can keep up with your preventative and follow-up medical care for the remainder of 2019. The Plan denied your request. The Plan says this service is not approved for coverage.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of additional non-emergent transportation have not been met. Your EOC clearly states, there are up to 50 one-way trips per calendar year; therefore, the 51st trip and beyond is not a covered benefit. Therefore, we decided that the Plan does not have to provide additional non-emergent transportation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous ablation and sclerotherapy. 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 endovenous ablation and sclerotherapy are covered when specific criteria are met. 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 do not document that you are having lifestyle-limiting symptoms due to varicose veins. It is not clear when you previously underwent vein ablation and sclerotherapy and the impact the procedures had on your symptoms. It is not clear if you regularly used medical grade compression stockings. There is no documented evidence of abnormal pedal pulses. The records do not support that your symptoms are due to varicose veins. The requested procedures are not reasonable or 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 not been met.Therefore, we decided that the Plan does not have to pre-approve endovenous ablation and sclerotherapy