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

We decided that the Plan does not have to pre-approve the Vertiflex interspinous spacer.
You asked the Plan to pre-approve the Vertiflex interspinous spacer. The Plan denied your request. The Plan
says this is 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 the Vertiflex interspinous spacer. Our
reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found that current evidence based medical guideline and peer reviewed literature do not
fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy.
There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for
this enrollee's medical condition. There is no compelling rationale presented or extenuating circumstances
noted to support the medical necessity of this request as an exception to guidelines.
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 Vertiflex interspinous spacer have not been met. Therefore, we decided that
the Plan does not have to pre-approve the Vertiflex interspinous spacer.
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 not require treatment by multiple therapies and there are no complex nursing or rehabilitation needs.
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 are available 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on July 22, 2020.
You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Cardiovascular risk assessment panels are only covered for certain indications. Review of the file shows that the plan uses Local Coverage Determination (LCD) L36523 to support their denial. However, LCD L36523 is not valid for the provider's billing state of Texas. Therefore, we are unable to use LCD L36523 to substantiate our decision. While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on July 22, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea.
You asked the Plan to pre-approve Eylea. You say that the enrollee has previously been treated with Avastin. The Plan denied your request. The Plan says the enrollee has not tried and failed bevacizumab ophthalmic.
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 Eylea. Our physician reviewer found that the enrollee has a history of macular degeneration. The Plan requires a trial of bevacizumab before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug. There is no documentation provided indicating that the Plan's required drug would likely be less effective 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 Eylea have not been met. Therefore, we decided that the Plan does not have to pre-approve Eylea.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for care in a SNF. The Plan denied your request. The Plan says the guidelines for services in a SNF have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there is no documentation that the enrollee requires skilled nursing services. The documentation does show that the enrollee requires skilled therapy services, however they are not required on a daily basis. The enrollee does not require the services on an inpatient basis, only in a SNF setting. Services in the home with home health care, or in a long-term care facility on a part-time basis appear to be appropriate 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam (92004) and extended ophthalmoscopy (92202) provided on December 8, 2020 by an OON provider.
You asked the Plan to pay for the eye exam (92004) and extended ophthalmoscopy (92202). You say that the enrollee did not have any input in choosing the optometrist they would be seen by. You also say that the treating provider does not know which enrollee's he will be seeing since he is assigned to a facility and given a chart of enrollees in need of his services. The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The Plan also says that prior authorization was not obtained.
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 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 eye exam (92004) and extended ophthalmoscopy (92202) provided on December 8, 2020 by an OON provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve left facet joint radiofrequency ablations (RFA) for the enrollee.
You asked the Plan to pre-approve these services. You say that the enrollee has had RFA in the past with excellent results lasting greater than 6 months. The Plan denied your request. The Plan says that that the records sent to us do not tell us anything about the enrollee's level of disability from his pain.
The Plan must follow Medicare rules. Medicare rules say that repeat thermal facet joint RFA at the same anatomic site is considered medically reasonable and necessary provided the patient had a minimum of consistent 50% improvement in pain for at least six (6) months or at least 50% consistent improvement in the ability to perform previously painful movements and ADLs as compared to baseline measurement using the same scale. 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 considered medically reasonable and necessary in this case. This is a repeat RFA not an initial RFA. The pain relief provided in the past meets the LCD criteria. Our physician reviewer found that the enrollee's condition meets Medicare criteria for 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 been met. Therefore, we decided that the Plan has to pre-approve left facet joint radiofrequency ablations (RFA) 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humalog.
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 self-administered drugs are not covered.
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 Humalog.
Benefits for these services 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oxygen concentrator and portable oxygen concentrator.
You asked the Plan to pre-approve an oxygen concentrator and portable oxygen concentrator. You say that the requested oxygen concentrator and portable oxygen concentrator are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested oxygen concentrator and portable oxygen concentrator.
The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen. 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 an oxygen concentrator and portable oxygen concentrator. Our reviewer says that the enrollee does not meet criteria for the requested oxygen concentrator and portable oxygen concentrator. Our physician reviewer found the medical records provided indicate a resting oxygen saturation of greater than 90%. The medical records do not support any of the
enumerated elements in the coverage criteria. The elements of the coverage criteria are not satisfied. The requested service is not recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an oxygen concentrator and portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator and portable oxygen concentrator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Coflex interspinous stabilization device (22867).
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this service is 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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy.
There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition. Food and Drug Administration (FDA) indications include the Coflex device is for use in one or two levels of lumbar stenosis from L1- L5 in skeletally mature patients with at least moderate impairment in function, who experience relief in flexion from their symptoms of leg/buttocks/groin pain, with or without back pain, and who have undergone at least six months of non-operative treatment. FDA contraindications include prior fusion or decompressive laminectomy, radiographically compromised vertebral bodies, severe facet hypertrophy, spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. There is imaging evidence of grade 1 anterior spondylolisthesis, with no discussion of spinal instability on flexion/extension films. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for the insertion of a Coflex interspinous stabilization device at the L4-L5 level 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 this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Coflex interspinous stabilization device (22867).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have 18 additional routine transportation trips.
You asked the Plan 18 additional routine transportation trips. You say that you do not have any other means of transportation to go to your doctors' visits. The Plan denied your request. The Plan says you have exhausted your transportation benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have 18 additional routine transportation trips.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a CT scan and an MRI provided on January 15, 2021.
You asked the Plan to waive the copayments for a CT scan and an MRI. You say that you should only owe a $150 copayment and nothing else. 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 a $0 copayment for mammograms and ultrasounds and a $150 copayment for all other diagnostic and nuclear medicine radiological services. If multiple test types are performed in the same day, multiple copayments will apply. You received a CT scan on January 15, 2021. Therefore, you are responsible to pay the allowed amount of $112.22, which is less than the $150 copayment. You received an MRI on January 15, 2021. Therefore, you are responsible to pay the $150 copayment. The total amount you owe is: $262.22. You have been asked to pay the total copayment amount of $262.22 for a CT scan and an MRI. A CT scan and an MRI fall within the outpatient diagnostic tests and therapeutic services and 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 copayments for a CT scan and an MRI provided on January 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the in network rate for the adjunctive pre-diagnostic testing (D0431), and the application of fluoride varnish (D1206) provided on February 3, 2021.
You asked the Plan to reimburse the in network rate for the pre-diagnostic testing and application of fluoride varnish. You say that you were informed by a plan representative that this dentist was in network with your plan. The Plan denied your request. The Plan says adjunctive pre-diagnostic testing is not listed as a covered service. The Plan says that application of fluoride varnish is not listed as a covered service either.
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 adjunctive pre-diagnostic testing and the application of fluoride varnish are not among those covered under this benefit, regardless of the dentist's network status with the Plan. Therefore, we decided that the Plan does not have to reimburse the in network rate for the adjunctive pre-diagnostic testing (D0431), and the application of fluoride varnish (D1206) provided on February 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on December 7, 2020.
You asked the Plan to pay for the dental services. You say that you had 1 tooth break off at the gum line. You say that you were referred to an oral surgeon for an extraction. You also say that you do not understand how this can be a frequency limitation. The Plan denied your request. The Plan says 1 limited oral evaluation is covered every 3 plan years. The Plan also says that the frequency limit has 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 and limited oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on September 9, 2020. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on December 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services with an out of network (OON) oral surgeon.
You asked the Plan to pre-approve the services with an OON oral surgeon. You say that you have cancer of the mouth and need adequate treatment from the requested OON provider. The Plan denied your request. The Plan says the services are available in the enrollee's primary care network.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.
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 with an OON oral surgeon. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician reviewer found the Plan's denial is medically justified on the basis that it is offering adequate care to meet the enrollee's medical needs through refer to a tertiary level network provider. There is nothing unique about the enrollee's condition that would make it medically necessary for her to see the requested OON provider. The Plan has shown that they have in-network providers who meet the Standards of Care required for treatment of the enrollee's condition. 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 with an OON oral surgeon have not been met. Therefore, we decided that the Plan does not have to pre-approve services with an out of network (OON) oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inhalation of nitrous oxide/analgesia (D9230).
You asked the Plan to pre-approve inhalation of nitrous oxide/analgesia. You say that this request is medically necessary. The Plan denied your request. The Plan says this is not a covered service under your supplemental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve inhalation of nitrous oxide/analgesia (D9230).