Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second diagnostic medial branch block.

You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your request. The Plan says there was 40% relief from the first shot.

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 block. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requirement is for dual blocks which produce 80% pain relief. In this case, the first set only produced 40% pain relief. This set should be interpreted as negative, and another pain generator should be sought. The requested second set 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 block have not been met. Therefore, we decided that the Plan does not have to pre-approve a second diagnostic medial branch block.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay an additional $19.12 from your coinsurance responsibility. We also
decided that the Plan does not have to waive the co-payment for the full amount that you are being charged
($1,912.36).

You asked the Plan to waive the co-payment for home health services. You say that you were never invoiced for
this service until now. The Plan denied your request. The Plan says that the correct coinsurance of 50% was
applied for these services.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as
co-payments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 50%
coinsurance for home health services.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
waiving the coinsurance are partially met in this case. Specifically, the record shows that you are being charged
$1912.36 for the home health services at issue. According to the Plan, this is based off an Allowed Amount of
$3786.48. 50% coinsurance from $3786.48 is $1,893.24. This means that you are being overcharged $19.12
($1912.36 - $1,893.24 = $19.12). The documentation within the record does not explain why you are being
charged $19.12 over the 50% coinsurance allowed for these services. Therefore, we decided that the Plan has to
pay an additional $19.12 from your coinsurance responsibility (bringing your total coinsurance and the Plan's
total share to $1,893.24 each).

The contract is clear however, that 50% coinsurance applies for Home Health Agency Care. This means that
the Plan does not have to waive your entire coinsurance responsibility for these services. This is a contractual
obligation that you agreed to pay when you enrolled with the Plan. Therefore, we also decided that the Plan
does not have to waive the co-payment for the full amount that you are being charged ($1,912.36).

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance services provided on March 3, 2020, and September 29, 2020.

You asked the Plan to pay for the services. 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 services are not among those covered under this benefit. The Plan contract clearly states that periodontal cleaning are excluded from coverage. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance services provided on March 3, 2020, and September 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 12, 2021.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing/panels.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the cardiovascular risk assessment performed with the laboratory tests are not evidence based and investigational and therefore not covered. 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 pay for laboratory services provided to the enrollee on January 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia, 60 mg/mL, subcutaneous syringe.

You asked the Plan to pre-approve Prolia. You say that the enrollee sustained a fragility fracture while on Fosamax treatment for osteoporosis. You say that the enrollee has since switched to Prolia which has been successful. You also say that the use of Prolia should be covered to prevent future fragility fractures and the cost associated with repair and rehabilitation of such an injury. The Plan denied your request. The Plan says the enrollee has not tried and failed zoledronic acid (generic Reclast). The Plan also says that the requested drug 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 Prolia. Our reviewer says that the Prolia syringe is not medically necessary. Our physician reviewer found the provided documentation indicates that the enrollee has tried and failed an oral bisphosphonate drug but has not tried and failed zoledronic acid. The reviewer also found that there is no indication that zoledronic acid would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy requirements have not been 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia, 60 mg/mL, subcutaneous syringe.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for aortic dysfunction or dilation genetic testing provided on February 14, 2020.You asked the Plan to pay for genetic testing. You say that this testing was ordered after the ordering physician made a professional determination of medical necessity.The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this testing is unlikely to impact therapeutic decision-making and the provider did not document how a positive gene test would impact treatment or change management.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Furthermore, the Plan cited Local Coverage Determination (LCD) L35000 to support their denial of payment; however, this LCD lacks jurisdiction in the geographic location where this laboratory testing was performed. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for aortic dysfunction or dilation genetic testing provided on February 14, 2020.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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implantable cardiac rhythm monitor.

You asked the Plan to pre-approve insertion, subcutaneous cardiac rhythm monitor, including programming (33285). You say that the enrollee needs an implantable cardiac rhythm monitor. The Plan denied your request. The Plan says the medical information shows the enrollee did not have an unexplained cryptogenic stroke or syncope.

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 insertion, subcutaneous cardiac rhythm monitor, including programming (33285). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a further assessment of bradycardia or possible heart block causing current non-specific symptoms would be using an external auto or patient triggered event monitor or a more prolonged external patch continuous electrocardiogram monitor to correlate symptoms with any significant rhythm abnormalities, particularly bradycardia. The use of a long-term implantable loop recorder at this stage of the evaluation, given the clinical scenario, would not be considered
medically necessary and would therefore not meet the applicable CMS Section 1862(a)1(A) medical necessity criteria.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion, subcutaneous cardiac rhythm monitor, including programming (33285) have not been met. Therefore, we decided that the Plan does not have to pre-approve an implantable cardiac rhythm monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre CGM and supplies.

You asked the Plan to pre-approve the CGM and supplies. You say that you feel that these items are medically necessary. The Plan denied your request. The Plan says the required criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day and use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre CGM and supplies.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve catheter placements in the coronary artery (93454,
93458), right and left heart catheterization (93453), and transcatheter placement of intracoronary stents (92928)
to be performed at an out of network tertiary care facility.

You asked the Plan to pre-approve catheter placements in the coronary artery, right and left heart
catheterization, and transcatheter placement of intracoronary stents to be performed at a tertiary care facility.
You say that the requested facility is more capable of safely assisting the enrollee. The Plan denied your
request. The Plan says services at a tertiary care facility 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 catheter placements in the coronary
artery, right and left heart catheterization, and transcatheter placement of intracoronary stents. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has aortic stenosis and coronary artery disease (CAD) and based on two separate opinions has elected percutaneous coronary intervention (PCI) and transcatheter aortic valve replacement (TAVR) rather than cardiac surgery with aortic valve replacement (AVR)/coronary artery bypass graft (CABG). The enrollee has been referred first for repeat left and right heart catheterization and PCI of significant coronary artery disease lesions. The procedures at issue of left and right heart cardiac catheterization, coronary angiography and PCI stent procedures are done routinely at many hospitals with qualified interventional cardiac/cardiac surgical programs. These procedures generally do not require referral to a tertiary center for this specific type of cardiac care unless there are very specific extenuating clinical circumstances (such as severe heart failure requiring a ventricular assist device). The enrollee is clinically stable with good left ventricle function and does not have a specific noted clinical reason requiring a tertiary center referral for these procedures, which can be performed by a qualified in-network facility and provider. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of catheter placements in the coronary artery, right and left heart catheterization, and transcatheter placement of intracoronary stents to be performed at a tertiary care facility have not been met. Therefore, we decided that the Plan does not have to pre-approve catheter placements in the coronary artery (93454, 93458), right and left heart catheterization (93453), and transcatheter placement of intracoronary stents (92928) to be performed at an out of network tertiary care facility.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve immunoglobin infusions (IVIG).

You asked the Plan to pre-approve IVIG. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that IVIG is used in the treatment of primary immunodeficiency diseases featuring low or dysfunctional antibody levels to prevent infection and for certain inflammatory, autoimmune and other diseases featuring to interfere with harmful antibodies and/or for blocking damage from immune cells.

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 IVIG. Our reviewer says that the services are medically necessary. Our physician reviewer found based on the medical records provided there is documentation that this enrollee meets the coverage criteria. Despite lack of definitive evidence in the records that the enrollee has Chronic Inflammatory Demyelinating Polyneuropathy (CDIP), there are multiple other less specific neurologic diagnoses (which could be assigned to this enrollee) in the Local Coverage Article which are listed as supporting of medical necessity for intravenous immunoglobulin including: G60.3, Idiopathic progressive neuropathy; G60.8, Other hereditary and idiopathic neuropathies and G61.89, Other inflammatory polyneuropathies.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IVIG have been met. Therefore, we decided that the Plan has to pre-approve immunoglobin infusions (IVIG).

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 preapprove a pneumatic compression device (E0651, E0667).
You asked the Plan to preapprove a pneumatic compression device. You say that you require the device. The
Plan denied your request. The Plan says the documentation did not show that you have tried and failed four
weeks of conservative therapy.
The Plan follows Medicare rules. The rules state that a PCD coded as E0650 or E0651 is covered for the
treatment of lymphedema after a four-week trial of conservative therapy demonstrating failed response to
compression garments, elevation, and exercise.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least
four weeks of conservative therapy. Therefore, we decided that the Plan does not have to preapprove a
pneumatic compression device (E0651, E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ensure formula.
You asked the Plan to pre-approve Ensure formula. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Ensure is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve Ensure formula.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient mental health care provided on January 28, 2021, to February 4, 2021.You asked the Plan towaive the copayment forinpatient mental health care. You say that the copayment amount is too much, and you were forced to go to the hospital against your will.The Plan denied your request. The Plan says the copayment you are being charged is correct.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 $350copayment per day, for days 1-5of inpatient mental health care. The Plan contract also says that you pay $0 for days 6 and beyond, for inpatient hospital care. You have been asked to pay a $350copayment per day for inpatient hospital care ($350 x 5 days = $1,750). The EOC confirms that $350per day is the required copayment for this service. 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 forinpatient mental health care provided on January 28, 2021, to February 4, 2021.Your complaint about the Plan's processing of your copayment obligation is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional occupational therapy visitsYou asked the Plan to pre-approveoccupational therapy. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of authorization for additional occupational therapy is correct, because this is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve occupational therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was already approved by the Plan. The enrollee has had 10 prior outpatient therapy visits, and the records do not show that the unique skills of a professional therapist are required to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist. The enrollee's function appears at baseline. The enrollee has the assistance of staff at her long-term care facility.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of occupational therapy have not been met.Therefore, we decided that the Plan does not have to pre-approveadditional occupational therapy visits