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

We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT).
You asked the Plan to pre-approve stereotactic body radiation therapy (SBRT). You say that stereotactic body radiation therapy (SBRT) is medically necessary. The Plan denied your request. The Plan says because you are participating in a clinical trial, this service must be appealed to Original Medicare first.
The Plan must follow Medicare rules. Medicare rules say that Medicare approved clinical trials and certain procedures that are part of the clinical trials program are covered by traditional Medicare, but they are not covered by the health plan. The request for coverage of SBRT must be submitted to Original Medicare first because you are participating in a clinical trial. Therefore, we decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to an out-of-network podiatrist.You asked the Plan to pre-approvethese services. You say that you have an upcoming appointment and are due for surgery on your left foot.The Plan denied your request. The Plan says the services are available from network providers.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-approvea referral to an out-of-network podiatrist.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay forneuromonitoring services (95907, 95861, 95813, 95868) provided on April 11, 2019. You asked the Plan to pay forthe neuromonitoring. You say that the service was medically necessary.The Plan denied your request. The Plan says that rules for coverage have not been met.The Plan must follow Medicare rules. Medicare rules say that if there areno specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Planwas correct in denying the request to pay for the neuromonitoring. Our reviewer says that the neuromonitoring and testing was medically necessary. Our physician reviewer found the neuromonitoring was requested by the primary surgeon performing the procedure due to the proximity of the spinal cord. Coverage criteria is 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 the neuromonitoring have been met.Therefore, we decided that the Plan has to pay forneuromonitoring services (95907, 95861, 95813, 95868) provided on April 11, 2019. 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 toopen the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for hypoxic respiratory failure. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is noadvantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the SNF services provided from July 7, 2019 to August 6, 2019.
You asked the Plan to pay for the SNF services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require daily skilled nursing and/or daily skilled rehabilitation services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pay for the SNF services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 pay for the SNF services provided from July 7, 2019 to August 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to adjust the payment for the lumbar orthotic flex provided on February 18, 2019 by the physician or reimburse you for the seat lift mechanism provided on October 22, 2019 by an out of network provider.
You asked the Plan to adjust the payment for the lumbar orthotic flex and reimburse you for the seat lift mechanism. You say that the Plan should reimburse you for the seat lift mechanism and reimburse you more for the lumbar orthotic. The Plan denied your request. The Plan says you did not request prior authorization for the out-of-network supplier of the seat lift mechanism, and you have been reimbursed the Medicare allowed amount for the orthotic minus your copayment.
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 has network providers available who can provide the seat lift mechanism at issue in this appeal. The Plan did not pre-approve the seat lift mechanism at issue. We found no exception that would require the Plan to pay for this items. You have been reimbursed the Medicare current rate for the orthotic. Therefore, we decided that the Plan does not have to adjust the payment for the lumbar orthotic flex provided on February 18, 2019 by the physician or reimburse you for the seat lift mechanism provided on October 22, 2019 by an out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on November 18, 2019.You asked the Plan to pay forthe non-emergent ambulance service. You say that the transport was medically necessary.The Plan denied your request. The Plan says you did not request prior authorization.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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 forthe ambulance services provided on November 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Gel-One knee injection.You asked the Plan to pre-approvethe injection. You say that this is medically necessary.The Plan denied your request. The Plan says six months must have elapsed since the previous injection.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 Medicarerules to determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no clinical documentation that the enrollee is having pain in her knee. In addition, there is insufficient support for this procedure in the medical literature. Studies in the peer-reviewed medical literature indicate that intraarticular hyaluronic acid produces a small, clinically irrelevant benefit over placebo.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 injection have not been met.Therefore, we decided that the Plan does not have to pre-approvea Gel-One knee injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea consultation and extraction to be provided by an Oral Surgeon.You asked the Plan to pre-approvethe consultation and extraction. You say that you went to the emergency room and were told you have an abscess on your right bottom tooth. You also say that you need to have the tooth taken out because your teeth are bad and need to come out.The Plan denied your request. The Plan says dental services performed by an Oral Surgeon are not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received by an oral surgeon. The Plan only covers dental services when they are performed by a participating general dentist.Therefore, we decided that the Plan does not have to pre-approvea consultation and extraction to be provided by an Oral Surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe cone beam CT capture and interpretation with field of view of both jaws (D0367), removal of lateral exostosis (maxilla or mandible) (D7471 x4), removal of torus mandibularis (D7473 x4), and therapeutic parenteral drug (D9610).You asked the Plan to pre-approvethe cone beam CT capture and interpretation, removal of lateral exostosis, removal of torus mandibularis, and therapeutic parenteral drug. You say that you are without teeth on the lower part of your mouth and are unable to eat well. You also say that you must have these procedures done in order to get any type of relief from your pain.The Plan denied your request. The Plan says these services are not covered under yourplan.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-approvethe cone beam CT capture and interpretation with field of view of both jaws (D0367), removal of lateral exostosis (maxilla or mandible) (D7471 x4), removal of torus mandibularis (D7473 x4), and therapeutic parenteral drug (D9610).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.You asked the Plan to pre-approve the Prolia. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the requested services are 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 Prolia. Our reviewer says that the member has not tried andfailed a trial of zoledronic acid. Our physician reviewer found without the support of the documentation, Prolia is not approved as step therapy criteria is 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 the Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs device.
You asked the Plan to pre-approve the CardioMEMs. You say that the CardioMEMs device is medically necessary. The Plan denied your request. The Plan says the records do not show that the member is enrolled in a Medicare-approved medical research study.
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 CardioMEMs. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. The device should still be considered experimental or investigational. 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 CardioMEMs have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMs device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a mandibular partial denture (D5214).
You asked the Plan to pre-approve the complete maxillary denture and mandibular partial denture. You say that you had 19 teeth removed and are having trouble swallowing food. You also say that you are on a limited income and cannot afford to pay for the dentures out of pocket. The Plan denied your request. The Plan says these services are not covered under your benefit package.
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 a complete maxillary denture (D5110) and a mandibular partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the first 15 minutes of deep sedation/general anesthesia and each subsequent 15 minute increment of deep sedation/general anesthesia. We decided that the Plan does not have to pre-approve the partial ostectomy/sequestrectomy for removal of non-vital bone. You asked the Plan to pre-approve the partial ostectomy/sequestrectomy for removal of non-vital bone.You say that you have a broken bone in your gum which is infected and you need to be put to sleep to take the chipped bone out of your gum.The Plan says that these services are not covered by Medicare.We decided that the Plan has to pre-approve the first 15 minutesof deep sedation/general anesthesia and each subsequent 15 minute increment of deep sedation/general anesthesia. The Plan follows Medicare rules. Medicare rules say that the Plan must provide you with a clear and accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits.The Evidence of Coverage clearly states that first 15 minutes of deep sedation/general anesthesia (D9222) and each subsequent 15 minute increment of deep sedation/general anesthesia (D9223) are covered services without limitations.Therefore, we decided that the Plan has to pre-approve the first 15 minutes of deep sedation/general anesthesia and each subsequent 15 minute increment of deep sedation/general anesthesia. We also decided that the Plan does not have to pre-approve the partial ostectomy/sequestrectomy for removal of non-vital bone.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve the partial ostectomy/sequestrectomy for removal of non-vital bone.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 pay for the knee orthosis and suspension sleeve provided on June 5, 2019.
You asked the Plan to pay for the knee orthosis (L1833) and suspension sleeve (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says rules for telehealth services were not met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on June 5, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveGenvisc.You asked the Plan to pre-approveGenvisc. You say that the requested Genvisc is medically necessary.The Plan denied your request. The Plan says the enrollee must try and fail Monovisc first.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 Genvisc. Our reviewer says that thePlan's step therapy criteria have not been met. Our physician reviewer found the enrollee has a diagnosis of unilateral primary osteoarthritis of the right and left knees. It is noted that the enrollee has received 3 injections of Orthovisc in her right and left knees. Great improvement in her pain was reported. The Plan requires a trial of Monovisc before they will approve the requested drug, Genvisc. Based on the documentation provided, the enrollee has not tried and failed treatment with Monovisc. The provider does not state that Monovisc would likely be less effective, and/or would likely have adverse effects for 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 Genvisc have not been met.Therefore, we decided that the Plan does not have to pre-approveGenvisc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the zero gravity bed purchased on September 5, 2019.
You asked the Plan to reimburse you for the zero gravity bed. You say that no one told you that you had to go through the facility to get an adjustable bed. The Plan denied your request. The Plan says commercially available furniture does not meet Durable Medical Equipment criteria.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position.
We looked at the file and Medicare rules. Once a prescription is attained, the bed must be supplied via a Medicare supplier who accepts assignment. You did not coordinate the bed through the Plan's supplier. Based on this information, we decided that Medicare rules for coverage of the adjustable bed have not been met. Therefore, we decided that the Plan does not have to reimburse you for the zero gravity bed purchased on September 5, 2019.