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

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there are not enough medical studies in the pipeline to support this treatment as beneficial.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this request is considered experimental and investigational compared to standard radiofrequency ablation. It is the subject of ongoing clinical trials to determine its role in the management of knee osteoarthritis.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantation of a bone conduction hearing device (Osseointegrated implant) for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this request is not a covered benefit.
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records indicate that the enrollee has unilateral mixed conductive and sensorineural hearing loss left ear with restricted hearing on the right. The record does not indicate that hearing aids are medically inappropriate or cannot be utilized due to congenital malformations, chronic disease, severe sensorineural hearing loss or surgery. The elements of the coverage rule 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve implantation of a bone conduction hearing device (Osseointegrated implant) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vasectomy (55250).

You asked the Plan to pre-approve a vasectomy. You say that the enrollee wants the procedure as a cautionary measure to prevent a pregnancy. The Plan denied your request. The Plan says there is no associated sexual dysfunction, hematuria or family history of cancer in the physician office notes.

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 record shows this surgery is not a necessary part of the treatment of an illness or injury. Based on this information, we decided that Medicare rules for coverage of a vasectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve a vasectomy (55250).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided to the enrollee on October 3, 2020.
You asked the Plan to pay for the stimulator. You say that this should be paid for. The Plan denied your request. The Plan says the submitted documents indicate that the services may have been administered by a health care provider other than the billing health care provider.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the CPT Code Manual definition of Healthcare Common Procedure Coding System code E0745 is "neuromuscular stimulator, electronic shock unit." The rules also say that DME supplies must be provided with a proof of delivery. We asked our coding 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 stimulator. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the documentation did not include proof of delivery; therefore, the services cannot be confirmed as performed. We looked at this coder's review, the file, and Medicare rules. The required documentation pertaining to the proof of delivery of these supplies was not provided. Based on this information, we decided that Medicare rules for coverage of the stimulator have not been met. Therefore, we decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided to the enrollee on October 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve leg surgery to be provided by an out-of-network
provider.

You asked the Plan to pre-approve amputation, leg, through tibia and fibula; re-amputation (27886) with an
out-of-network provider. You say that the enrollee was referred to you because of your experience in
amputation revision. The Plan denied your request. The Plan says they have in-network providers who can
provide this surgery.

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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve leg surgery
to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service 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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested device is experimental. More research is needed to show safety and efficacy of the device. 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Afirma assay rendered on November 5, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that the Afirma assay is 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee had a single right non-toxic thyroid nodule. The documentation in the case file is limited to a Requisition Form & Statement of Medical Necessity, the biopsy report, and the results of the testing. A needle core biopsy on October 27, 2020, was not highly compelling for papillary thyroid carcinoma, but the possibility could not be excluded. The documentation is insufficient to demonstrate that the enrollee has a history suggesting malignancy or the characteristics suggesting malignancy. The criteria for coverage are not met and the testing was therefore not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the Afirma assay rendered on November 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound of heart (93306) provided on January 19, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the ultrasound of heart. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON 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 pay for 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the ultrasound of heart (93306) provided on January 19, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.
You asked the Plan to pre-approve a stair glide. You say that you are trying to stay healthy and active but find it difficult getting up the stairs without assistance. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the enrollee has not
met the step therapy requirements. Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Euflexxa. Our reviewer says that
Euflexxa is not medically reasonable and necessary in this case. Our physician reviewer found that based on
the medical records provided, the enrollee has tried and failed Monovisc, but he has not tried and failed
Orthovisc. There is no indication that Orthovisc would likely be less effective and/or likely have adverse
effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have
to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).

You asked the Plan to pre-approve the total electric hospital bed. You say that a new total electric hospital bed
is medically necessary. The Plan denied your request. The Plan says this is not a covered item.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital
bed (E0265).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic manipulative treatment (98941), electric stimulation therapy (97014), therapeutic exercises (97110), and manual therapy (97140) to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested services.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve chiropractic manipulative treatment (98941), electric stimulation therapy (97014), therapeutic exercises (97110), and manual therapy (97140) to be rendered by the out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services (80061, 83036) provided on March 29, 2021.

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 services 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 $10 per day for other Medicare-covered laboratory tests that are not FIT tests.

You have been asked to pay a $10 copayment for the Medicare-covered laboratory tests 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 laboratory services (80061, 83036) provided on March 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane 60 MG/3 ML Syringe.

You asked the Plan to pre-approve Durolane 60 MG/3 ML Syringe. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step
therapy criteria.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.

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 Durolane 60 MG/3 ML Syringe. Our
reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our
physician reviewer found the enrollee has pain related to osteoarthritis of both knees. The enrollee has failed
conservative treatment and prior treatment with Orthovisc injections. The documentation does not support that
the enrollee has tried and failed Monovisc. The documentation does not support and indication that the plan's
required drug would likely be less effective and/or likely have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Durolane 60 MG/3 ML Syringe have not been met. Therefore, we decided that
the Plan does not have to pre-approve Durolane 60 MG/3 ML Syringe.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four implant procedures (D6199 x4).

You asked the Plan to pre-approve the implant procedures. You say that you cannot wear a partial denture due
to having multiple seizures a day, and the dentures would cause a choking hazard. The Plan denied your
request. The Plan says these services are not covered under your benefit package.

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 four
implant procedures (D6199 x4).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergency transportation trips (A0110).
You asked the Plan to pre-approve additional non-emergency transportation trips. You say that you have no transportation to get to appointments. The Plan denied your request. The Plan says you have utilized the maximum number of transportation trips allowed per year.
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. The Plan covers a maximum of 32 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional non-emergency transportation trips (A0110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump identified with code E0218.

You asked the Plan to pre-approve a fluid circulating cold pad with pump. You say that you feel this should be covered because it was recommended by your doctor. The Plan denied your request. The Plan says the requested item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump will be denied as not reasonable and necessary. 

We looked at the file and Medicare rules. The request is for a fluid circulating cold pad with pump. This item is not a covered benefit. Based on this information, we decided that Medicare rules for coverage of a fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump identified with code E0218.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral x-ray and fluoride varnish application provided on March 30, 2021.

You asked the Plan to pay for the additional intraoral x-ray and fluoride varnish application. You say that you were not informed the images and fluoride varnish were not covered by the Plan in advanced. You say that these should be covered if they are necessary. The Plan denied your request. The Plan says intraoral x-rays are only covered once per calendar year and the fluoride varnish application 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, you also have a maximum benefit of one intraoral x-ray per calendar year. The Plan paid for one intraoral x-ray provided on March 30, 2021, which exhausted your benefit. The fluoride varnish application is not a covered benefit. Therefore, we decided that the Plan does not have to pay for the additional intraoral x-ray and fluoride varnish application provided on March 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D2950).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 dental services (D2950).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis. The requested Vertiflex Superion spacer is considered experimental/investigational in nature, as more research is needed to show safety and efficacy. The services are therefore not reasonable or medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.