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

We decided that the Plan does not have to pre-approve injections of lower or sacral spine facet joint using
imaging guidance for the enrollee.

You asked the Plan to pre-approve injections for the enrollee. You say that this treatment is medically
necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Qualified Independent Contractor (QIC) overturned the Plans denial. The Plan requested a reopen and stated that the QIC did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for injection(s),
diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with
image guidance (fluoroscopy or CT), lumbar or sacral: second level (L5&#8208;S1) x 2. The QIC Physician
Reviewer determined that the enrollee has chronic low back pain, which does not radiate. The enrollee is status
post L4-L5 laminectomy. The enrollee had one set of diagnostic medial branch blocks and achieved 80% pain
relief. The documentation shows that the enrollee meets criteria for a second diagnostic set of medial branch
blocks. The Plan argues that they do not disagree that repeat diagnostic injections are appropriate and medically
necessary. The point of dispute is the number of injections requested exceeding the Medicare limitation.

Our Medical Director has concluded that the Plan is correct in this case. LCD L34832 states that, if after the
first MBB injection, the patient experiences greater or equal to 80% relief of their primary (index) pain, lasting
a time period consistent with the local anesthetic used, the patient may undergo a second, confirmatory MBB.
Two diagnostic injections are allowed per region irrespective of the joints injected with maximum of 2 joints
allowable per session per region. Medicare coverage criteria were not met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of injections of lower or sacral spine facet joint using imaging guidance have not
been met. Therefore, we decided that the Plan does not have to pre-approve injections of lower or sacral spine
facet joint using imaging guidance for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for non-complex chronic care management (99490} provided on February 28, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the chronic care management. You say that you have enclosed the supporting medical records to prove the need for the services rendered The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 non-complex chronic care management (99490} provided on February 28, 2021 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure (22899, C9752, C9753).

You asked the Plan to pre-approve these services. You say that your doctor is recommending this procedure to help improve your severe and chronic back pain. The Plan denied your request. The Plan says that experimental and investigational procedures are not covered by Medicare.

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 requested services are not considered medically reasonable and necessary in this case. Detailed documentation is not evident regarding Modic type I or II at the requested surgery levels. Furthermore, multiple other plausible pain generators (including at the lumbosacral spine) are evident including lumbar stenosis, facet arthropathy, radiculopathy and SI joint pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Our physician reviewer found that your condition does not meet criteria for coverage of these services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure (22899, C9752, C9753).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus Gene Panel rendered on February 15, 2021.

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 molecular pathology 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 has a diagnosis of malignant neoplasm of esophagus (gastric cancer antrum). The documentation does not support the medical necessity of genetic testing consisting of 105 genes. It has not been demonstrated that this genetic testing panel is medically necessary and will impact the management and outcome of the enrollee in this case. 

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 Tempus Gene Panel rendered on February 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture treatment to be rendered by the out of network (OON) provider.

You asked the Plan to pre-approve this service. 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 service.

The Plan must follow Medicare rules. Medicare rules state that plans must make care available and accessible to you. 

Maximus has confirmed that the Plan has providers within a reasonable distance from your home available to provide the services you need. Therefore, we decided that the Plan does not have to pre-approve acupuncture treatment to be rendered by the out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve brachytherapy radiation therapy for the enrollee.

You asked the Plan to pre-approve brachytherapy radiation therapy. You say that this treatment is medically
necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for brachytherapy
radiation therapy. The Maximus Physician Reviewer determined that for high-risk prostate cancer,
brachytherapy alone does not follow the recommendations of NCCN guidelines, AUA/ASTRO/SUO
Guidelines or American Society of Clinical Oncology/Cancer Care Ontario Joint Guidelines. Nevertheless,
there are data to support its use, therefore, medical necessity has been established. The Plan requested a reopen
stating that using all information available, as well as every appropriate specialty body, it was appropriate to
deny this request for brachytherapy radiation therapy. Our Medical Director has concluded that the Plan is
correct in this case. The medical records show the enrollee is an 82-year-old man with a diagnosis of high-risk
prostate cancer. There is insufficient documentation in the medical literature to demonstrate that brachytherapy
alone is an accepted standard of care for the treatment of high-risk prostate cancer. Medical necessity has not
been established.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of brachytherapy radiation therapy have not been met. Therefore, we decided that
the Plan does not have to pre-approve brachytherapy radiation therapy for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One for the enrollee.

You asked the Plan to pre-approve Synvisc-One. You say that Synvisc-One is medically necessary for the
enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus
overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct
criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for Synvisc-One. The
Maximus Physician Reviewer determined that the physical exam was consistent with osteoarthritis. "Although
the plain x-ray was not consistent with osteoarthritis, magnetic resonance scanning has been reported in the
medical literature to identify osteoarthritis at earlier stages of disease before plain x-ray changes become
apparent. The Synvisc-One is safe and effective and reasonable and medically necessary at this time."
The Plan argues that both plain imaging and MRI failed to show evidence of osteoarthritis.

Our Medical Director has concluded that the Plan is correct in this case. Synvisc-One is indicated for the
treatment of pain in osteoarthritis of the knee in patients who have failed to respond adequately to conservative
nonpharmacologic therapy and simple analgesics. The documentation in the case file does not support a
diagnosis of osteoarthritis of the knee for the enrollee in this case. Medicare coverage criteria are not met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have
to pre-approve Synvisc-One for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Denosumab for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no evidence of metastatic disease to bone.

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 the drug. Our reviewer says that the requested drug is medically reasonable and necessary. Our physician reviewer found per the Medicare-approved compendia, this drug is allowed for patients over 70, with non-metastatic disease on luteinizing hormone-releasing hormone. 

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 drug have been met. Therefore, we decided that the Plan has to pre-approve Denosumab for the enrollee.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for continuation of inpatient services provided after June 1, 2021.

You asked the Plan to provide coverage for continuation of inpatient services. The Plan denied your request. The Plan says that the member has exhausted the inpatient hospital care benefit of 90 days for this benefit period and exhausted the 60 one-time use lifetime reserve days. After June 1, 2021 there is no additional benefit for inpatient days, with the exception of coverage for physician services, diagnostic tests, radiology services, physical therapy, etc.

The Plan must follow Medicare rules. Medicare rules say that up to 90 days are available in each benefit period. Each beneficiary has a non-renewable lifetime reserve of 60 days of inpatient hospital services that he may draw upon whenever he is hospitalized for more than 90 days in a benefit period. 

We looked at the file and Medicare rules. The file shows that 150 days of inpatient an stay have been used as of June 1, 2021. Based on this information, we decided that Medicare rules for coverage of continuation of inpatient services have not been met. Therefore, we decided that the Plan does not have to provide coverage for continuation of inpatient services provided after June 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ubrelvy for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is necessary to treat the enrollee's migraines. The Plan denied your request. The Plan says that this is not covered under Part B.

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 Ubrelvy for the enrollee.

Benefits for this drug 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 inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.

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 patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program.

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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950).

You asked the Plan to pre-approve the core buildup. The Plan denied your request. The Plan says this service is not covered.

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 a core buildup, including any pins when required (D2950).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on July 29, 2020, and July 30, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

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 services at issue in this appeal. 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 the services provided by an out-of-network provider on July 29, 2020, and July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia provided on February 1, 2021.

You asked the Plan to pay for the anesthesia (01992). You say that the anesthesia was necessary during the procedure. The Plan denied your request. The Plan says CPT 01992 and CPT 62321 cannot be billed together.

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 does not establish that the moderate sedation was medically necessary. Based on this information, we decided that Medicare rules for coverage of the anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia provided on February 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on October 5, 2020 by an out of
network (OON) provider.

You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and paid. The
Plan denied your request. The Plan says prior authorization was not obtained for these 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 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 an office visit provided on October 5, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on May 2, 2020 by an out of network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the member's primary care physician did not refer these 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 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 lab work provided on May 2, 2020 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 wound care services provided on January 7, 2021.

You asked the Plan to pay for the wound care services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the claim POS code 32 is incorrect.

The Plan must follow Medicare rules. Medicare rules say that when completing the 1500 claim form, providers must enter the correct Place of Service (POS) code in section 24B. Invalid or incorrect POS codes will be denied and returned to the provider.

In this case, the wound care services cannot be paid as billed due to an error with the POS code reported. Medicare billing criteria are not met. Specifically, the enrollee was in a covered SNF stay. Therefore, we decided that the Plan does not have to pay for the wound care services provided on January 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on December 17, 2020 by an out of network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 lab work provided on December 17, 2020 by an out of network (OON) provider.