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

We decided that the Plan does not have to pre-approve an absorbable nasal implant for the enrollee.

You asked the Plan to pre-approve the implant. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and unproven.

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 implant. 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 documentation does not indicate why an absorbable nasal implant is medically necessary for the enrollee's condition. Therefore, the requested service cannot be recommended under Medicare rules. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the implant have not been met. Therefore, we decided that the Plan does not have to pre-approve an absorbable nasal implant for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontics consultation and treatment.

You asked the Plan to pre-approve endodontics consultation and treatment. You say that you feel these services should be covered under your medical insurance because you believe this is more of a medical than a dental service. The Plan denied your request. The Plan says the requested services are not covered.

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 services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve endodontics consultation and treatment.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) provided by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that you would like the Plan to pay for your visit with your previous provider. The Plan denied your request. The Plan says criteria for out-of-network coverage for the service were not 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 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 office visit (99213) provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special anesthesia services.

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 procedure code 99100 is not separately payable.

The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified.

We looked at the file and Medicare rules. Billed procedure code 99100 (special anesthesia service) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the special anesthesia services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the total disc arthroplasty (22857, 0163T).

You asked the Plan to pre-approve the total disc arthroplasty. You say that this service is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that the service is helpful for the enrollee's condition.

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 total disc arthroplasty. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the patient has multilevel lumbar disc degeneration. Multilevel lumbar total disc replacement remains experimental for the treatment of lumbar degenerative disc condition. More research is needed to establish the safety and efficacy of the multilevel procedure.

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 total disc arthroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve the total disc arthroplasty (22857, 0163T).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for MammaPrint testing (81521).

You asked the Plan to pay for MammaPrint testing. You say that this should be covered. The Plan denied your request. The Plan says the enrollee's cancer was not in an early stage, so this was not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that MammaPrint was prospectively validated in the 6,693 patient Microarray In Node-negative Disease may Avoid ChemoTherapy (MINDACT) trial in early stage breast cancer, up to 3 positive lymph nodes.

We looked at the file and Medicare rules. The record shows that the enrollee had 4 positive lymph nodes. Based on this information, we decided that Medicare rules for coverage of MammaPrint testing have not been met. Therefore, we decided that the Plan does not have to pay for MammaPrint testing (81521).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation, two preventive procedures, and full mouth debridement.

You asked the Plan to pay for the comprehensive periodontal evaluation, preventive procedures, and full mouth debridement. You say that you were advised that you could see any dentist. The Plan denied your request. The Plan says these services were rendered by a provider who opted out of Medicare. The Plan also says that you were contacted by the Plan, and asked if you had any questions about your plan benefits, you said you did not.

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 covered when they are rendered by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation, two preventive procedures, and full mouth debridement.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient does not require services at the LTACH that are not already available at the current facility. In addition, there are no services at the LTACH that the patient requires now that are not already available and covered at the current facility. Transfer to a lower level of care may be considered soon when treatment has completed and the patient's new baseline is more clear.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the partial upper denture (D5213).

You asked the Plan to pre-approve the partial upper denture. You say that this service is medically necessary. The Plan denied your request. The Plan says this 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 pre-approve the partial upper denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft (D7953), the periodontal scaling and root planing (D4341 x 4), and the periapical x-ray (D0230).

You asked the Plan to pay for the dental services. You say that you did not receive any benefits. You say that you have been paying out of pocket for the services. You also say that you have not received any dental coverage. The Plan denied your request. The Plan says bone replacement graft is no listed as a covered service. The Plan says that periodontal scaling and root planing is covered once every 3 calendar years. The Plan says 1 periapical x-ray is covered every year. The Plan also says that the frequency limits for these services have been exceeded.

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, bone replacement graft is not among those covered under this benefit. The frequency limits for periodontal scaling and root planing, and periapical x-ray have been exceeded. The record shows that the Plan paid for periodontal scaling and root planing that you received. The record also shows that the plan paid for the initial periapical x-ray that you received on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the bone replacement graft (D7953), the periodontal scaling and root planing (D4341 x 4), and the periapical x-ray (D0230).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the coinsurance for outpatient surgery services.

You asked the Plan to waive the coinsurance for the outpatient surgery services. You say that you would like reconsideration because you called the Plan prior to the services being rendered and were told that you would only be responsible for the office visit copayment. You also state that you received services from an out-of-network provider because all in-network providers were inaccessible. The Plan denied your request. The Plan says that the claim was processed correctly, and the appropriate benefits were applied.

Medicare rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information to the Independent Review Entity (IRE). The Plan follows these rules.

The record indicates that you called the Plan to verify your benefits prior to the services being rendered. The customer service representative is an agent of the Plan. The Plan acknowledges that this call took place but has not included the customer service records in the submitted documentation. Additionally, the Plan has not included sufficient information to show that network providers were available to render this service. Under Medicare rules, this means the outpatient surgery services are considered approved by the Plan. Therefore, we decided that the Plan has to waive the coinsurance for outpatient surgery services.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat (E0244) and a tub stool or bench (E0245).

You asked the Plan to pre-approve a raised toilet seat and a tub stool or bench. You say that you have been falling and cannot walk well and cannot lift your legs to get into the tub. The Plan denied your request. The Plan says the requested items are not covered by Medicare.

The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. A tub stool or bench 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 raised toilet seat (E0244) and a tub stool or bench (E0245).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS system.

You asked the Plan to pre-approve a CardioMEMS system. You say that the CardioMEMS system will allow
the enrollee to better monitor and manage her symptoms that could lead to repeat heart failure hospitalizations.
The Plan denied your request. The Plan says the requested device is considered investigational and 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 a CardioMEMS system. Our reviewer
says that a CardioMEMS system is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee has a diagnosis of Acute on chronic systolic (congestive) heart failure, as
well as coronary artery disease, sick sinus syndrome, severe precapillary pulmonary hypertension,
hypertension, chronic kidney disease, and COPD. The enrollee was recently hospitalized. The efficacy of the
CardioMEMS heart failure system remains uncertain at this time. Further clinical study is needed to determine
the efficacy and safety of this 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 a CardioMEMS system have not been met. Therefore, we decided that the Plan
does not have to pre-approve a CardioMEMS system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the brand specific respiratory device to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the brand specific respiratory device. You say that this service is medically necessary. The Plan denied your request. The Plan says in-network benefits are available for 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 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 brand specific respiratory device to be provided by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the monitoring services.

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 procedure code G0453 is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code G0453 is continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary procedure).

We find that CPT code G0453 is not supported in the medical record. Specifically, there is no documentation of the duration of time that the continuous intraoperative neurophysiology monitoring was performed. 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 monitoring services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Insulin Lispro Kwikpen.

You asked the Plan to pre-approve the Insulin Lispro Kwikpen. The Plan denied your request. The Plan says the enrollee does not have a pharmacy benefit with the Plan, and Insulin Lispro Kwikpen is covered by the pharmacy 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 Insulin Lispro Kwikpen.

Benefits for the Insulin Lispro Kwikpen 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: 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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for COVID 19 infection and anemia. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan (J7321).

You asked the Plan to pre-approve Hyalgan. You say that the enrollee is in pain. The Plan denied your request. The Plan says this request does not meet the Plan's Part B step therapy criteria for the requested agent.

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 Hyalgan. Our reviewer says that Hyalgan is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial of drugs Orthovisc and Monovisc before they will approve the requested drug. Our reviewer found that in this case, the enrollee has not tried and failed the required drugs. Our physician reviewer also found that there is no documentation provided indicating that the Plan's required drugs 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan (J7321).