Persius/hicric huggingface dataset:
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.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 16, 2021.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility.
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 subsequent nursing facility care provided on March 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lymphedema sequential 2 chamber pump and leg sleeves (CPT code(s): E0651 and E0667) to be provided by an out-of-network DME company.
You asked the Plan to pre-approve the DME. You say that the DME cannot be supplied in-network. The Plan denied your request. The Plan says there are in-network providers available who can supply the requested DME.
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 lymphedema sequential 2 chamber pump and leg sleeves (CPT code(s): E0651 and E0667) to be provided by an out-of-network DME company
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the home infusion therapy provided January 8, 2021.

You asked the Plan to waive the coinsurance for the home infusion therapy. You say that you would like this coinsurance waived. The Plan denied your request. The Plan says the cost share has processed correctly in this case.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for home infusion therapy. 

You have been asked to pay a 20% coinsurance for the home infusion therapy. These services fall within the home infusion therapy benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the home infusion therapy provided January 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve anesthesia for percutaneous image guided procedures on the spine and spinal cord; therapeutic (CPT code 01932).
You asked the Plan to pre-approve the anesthesia. You say that the services are necessary. The Plan denied your request. The Plan says your records show you will be having injections of your paravertebral facet nerves. The Plan states they have authorized facet nerve blocks at the L1, L2, and L3 levels. The Plan states the record sent by your provider indicates you have facet-mediated low back pain and prior facet nerve blocks have proven helpful although temporarily. The Plan states your doctor does not document any rare or unique circumstances necessitating sedation or anesthesia.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the anesthesia have not been met. The rules say that general anesthesia is considered not medically reasonable and necessary for facet joint interventions. Neither conscious sedation nor Monitored Anesthesia Care (MAC) is routinely necessary for intraarticular facet joint injections or medial branch blocks and are not routinely considered medically reasonable and necessary. Individual consideration may be given on redetermination (appeal) for payment in rare, unique circumstances if the
medical necessity of sedation is unequivocal and clearly documented in the medical record. Frequent reporting of these services together may trigger focused medical review. Therefore, we decided that the Plan does not have to pre-approve anesthesia for percutaneous image guided procedures on the spine and spinal cord; therapeutic (CPT code 01932).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the evaluation for heart transplant to be performed by an out-of-network cardiologist.

You asked the Plan to pre-approve the evaluation. You say that the heart transplant program was approved by CMS on June 8, 2021, at this facility. The Plan denied your request. The Plan says this facility is not in-network for heart transplants. The Plan states they have transplant facilities that can provide a transplant evaluation.

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 evaluation for heart transplant to be performed by an out-of-network cardiologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three resin-based composites (codes D2331, D2335, and D2392) provided on March 26, 2021.
You asked the Plan to pay for the resin-based composites. You say that you were specifically told that fillings were covered. You also say that you cannot afford to pay for these charges. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan. The Plan also says that you were never enrolled in the dental rider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the three resin-based composites (codes D2331, D2335, and D2392) provided on March 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continued inpatient psychiatric hospital admission from August 2, 2021, forward.

You asked the Plan to pre-approve the continued inpatient psychiatric hospital admission. You say that the enrollee needs to continue inpatient care as they need stabilization and have active psychosis which will deteriorate without this level of care. The Plan denied your request. The Plan says the continued inpatient psychiatric hospital stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 continued inpatient psychiatric hospital admission. Our reviewer says that the inpatient psychiatric hospital admission is not medically necessary. Our physician reviewer found this enrollee did not require inpatient mental health treatment from August 2, 2021, forward as he was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. Based upon review the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment from August 2, 2021, forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. 

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 continued inpatient psychiatric hospital admission have not been met. Therefore, we decided that the Plan does not have to pre-approve the continued inpatient psychiatric hospital admission from August 2, 2021, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the immunohistochemistry services coded 88342 provided on
March 15, 2021.
You asked the Plan to pay for the immunohistochemistry services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 88342 is immunohistochemistry or
immunocytochemistry, per specimen; initial single antibody stain procedure.
We find that CPT code 88342 is not supported in the medical record. Specifically, this code was billed with
modifiers 26 and XU. Code 88360 (Morphometric analysis, tumor immunohistochemistry (eg, Her-2/neu,
estrogen receptor/progesterone receptor), quantitative or semiquantitative, per specimen, each single antibody stain procedure; manual) was billed under the same claim for the same date of service. The documentation does not support the use of code 88342-26,XU as performed by the provider. Based on this information, we decided that Medicare rules for coverage of the immunohistochemistry services have not been met. Therefore, we decided that the Plan does not have to pay for the immunohistochemistry services coded 88342 provided on March 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for home infusion services provided on
January 22, 2021.
You asked the Plan to waive the coinsurance for home infusion services. You say that you have already paid
upon delivery of prescription and are dissatisfied with the additional charges. The Plan denied your request.
The Plan says the correct coinsurance was applied.
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 20%
coinsurance for home infusion therapy.
You have been asked to pay $80.64, or 20% of the Medicare-allowed charge of $403.20, for home infusion
services. 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 coinsurance for home infusion services provided on January
22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on January 1, 2021.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you are dissatisfied with the additional charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 20% coinsurance for DME and related supplies. You received DME and related supplies on January 1, 2021. The total allowed amount is $403.20 and 20% of that is $80.64.
You have been asked to pay the total coinsurance amount of $80.64 for DME and related supplies. DME and
related supplies fall within the DME and related supplies benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the coinsurance for DME and related supplies provided on January 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Variantyx testing.
You asked the Plan to pre-approve genetic testing. You say that this testing is needed so you can have a positive diagnosis for the cause of your condition. The Plan denied your request. The Plan says the denial of authorization for this testing is correct, because whole exome sequencing is considered medically necessary for the evaluation of unexplained congenital or neurodevelopmental disorders in children under 21 years of age but you are not under 21 years of age.
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 genetic testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this testing is unlikely to impact therapeutic decision-making in your clinical management. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Variantyx testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses and lenses (V2750, V2781, V2784) provided on April 23, 2021.
You asked the Plan to pay an additional amount for eyeglasses and lenses. You say that you do not feel like the $200 allowed amount was deducted from the purchase of your eyeglasses and you would like the claim to be reprocessed and paid. The Plan denied your request. The Plan says the claim was processed according to the member's 2021 benefits.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan offers a $200 allowance per year toward the purchase and fitting of eyeglasses and lenses or contact lenses. We looked at the file and the Plan's rules. The records show that the retail price for your glasses was $640. The provider subtracted your $200 allowance which left a balance of $440. The provider then applied a 20% off discount, which came to $88. This brought your total balance due to $352. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses and lenses (V2750, V2781, V2784) provided on April 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX 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 this is not medically necessary.

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 the drug. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee has only tried and failed Monovisc. There must be a trial and failure of both Orthovisc and Monovisc. 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz FX for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Kyphoplasty T-9, T-11, T-12, L-5 (CPT code(s): 22515, 22513, 22514), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says all patients presenting with vertebral compression fractures (VCF) should be referred for evaluation of bone mineral density
and osteoporosis education for subsequent treatment as indicated and instructed to take part in an osteoporosis prevention/treatment program; however, the documentation does not support the criteria
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. physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures Furthermore, magnetic resonance imaging (MRIs) demonstrated chronic compression fractures T12 and L5. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for Kyphoplasty at T9, T11, T12, L5 (CPT 22515, 22513, 22514) is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve Kyphoplasty T-9, T-11, T-12, L-5 (CPT code(s): 22515, 22513, 22514), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology tests provided on November 18, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for pathology tests. 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. The Plan says that the referring provider is out-of-network.
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 pathology tests provided on November 18, 2020
by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion or replacement of neurostimulator system for treatment of central sleep apnea; complete system (transvenous placement of right or left stimulation lead, sensing lead, implantable pulse generator (CPT code 0424T), for the enrollee.

You asked the Plan to pre-approve the services. You say that the enrollee has attempted and failed conventional treatment including supplemental oxygen therapy, CPAP/mask desensitization, and BiPAP with symptoms that persist to interfere with their safety, wellbeing, and quality of life. The Plan denied your request. The Plan says Medicare says placement of this device diaphragmatic/phrenic nerve stimulation and diaphragm pacing systems are considered not medically necessary for central sleep apnea. The Plan states the information they have show that the enrollee has central sleep apnea.

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 items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is currently undergoing clinical trials in the treatment of CSA, and this enrollee is not part of a trial. Its effectiveness in the treatment of this condition has not been established. Furthermore, the records do not provide evidence that CPAP or BiPAP have been tried and failed, citing only the enrollee's report that they had tried it in the past and did not like it. The denial is upheld. 

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 insertion or replacement of neurostimulator system for treatment of central sleep apnea; complete system (transvenous placement of right or left stimulation lead, sensing lead, implantable pulse generator (CPT code 0424T), for the enrollee.