Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing (0037U) provided July 8, 2020.

You asked the Plan to pay for the genetic testing. You say that the genetic testing was medically necessary. The
Plan denied your request. The Plan says that the testing performed was investigational and not medically
necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no 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 Plan was correct in denying the request to pay for the genetic testing. Our reviewer says that
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer
found individualized molecular tumor profiling holds the promise of enabling personalized selection of
molecularly targeted treatment based on the specific genotype identified. Molecular profiling is now considered
a standard of care in patients with recurrent or persistent ovarian cancer. NCCN Guidelines recommend tumor
molecular testing prior to initiation of therapy for recurrent or persistent ovarian cancer if not previously done.

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 genetic testing have been met. Therefore, we decided that the Plan has to
pay for genetic testing (0037U) provided July 8, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.

You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that you have been using this device for 2 years and need to continue using it. The Plan denied your request. The Plan says the coverage criteria for a therapeutic continuous glucose monitor have 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 you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee scooter crutch substitute (E0118).
You asked the Plan to pre-approve a knee scooter. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that there is insufficient published clinical literature demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for products billed using E0118. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a knee scooter have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a knee scooter crutch substitute (E0118).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110).

You asked the Plan to pre-approve the denture. You say that your current dentures are causing you problems
and your dental provider said you would be able to get a new pair. The Plan denied your request. The Plan says
a complete upper denture can only be covered once every 5 years. You had a complete upper denture provided
and paid for in 2018. This is less than 5 years ago, so a new complete denture for the upper jaw cannot be
approved.

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 denture is requested in a frequency
that is not covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
complete upper denture (D5110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in tub.
You asked the Plan to pre-approve these services. You say that you are at risk for falls when getting into the tub. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a walk-in tub.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the eye exam and the OCT to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the eye exam and the OCT. You say that you trust your doctor completely and would like him to be approved as an out of network provider. The Plan denied your request. The Plan says the 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 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 eye exam and the OCT to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex implant, insertion of
interlaminar/interspinous process stabilization/distraction device (22869).

You asked the Plan to pre-approve the Vertiflex device. You say that you are recommending Vertiflex for the
enrollee based on it being the best treatment for moderate lumbar spinal stenosis with neurogenic claudication.
The Plan denied your request. The Plan says the information provided did not establish the service is
reasonable or 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 device. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and
efficacy of the device.

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 device have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Vertiflex implant, insertion of interlaminar/interspinous process
stabilization/distraction device (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that your feet collapse when you stand and walk.
The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foam dressing.

You asked the Plan to pre-approve foam dressing. You say that you need foam dressings. The Plan denied your request. The Plan says you do not have any skin wounds and do not meet the criteria for coverage.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We looked at the file and Medicare rules. The clinical assessment does not show you have a full thickness wound. Based on this information, we decided that Medicare rules for coverage of foam dressing have not been met. Therefore, we decided that the Plan does not have to pre-approve foam dressing.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation of the medical branch blocks.

You asked the Plan to pre-approve radiofrequency ablation of the medical branch blocks. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation of the medical branch blocks are only covered for certain indications.

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 radiofrequency ablation of the medical branch blocks. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has chronic neck pain. The enrollee takes Flexeril, Hydrocodone and Mobic for pain. There is no documentation of physical therapy. The enrollee had intra-articular facet injections. The LCD requires medical branch blocks not intra-articular injections. Therefore, the enrollee does not meet criteria for the requested services.

Review of the file shows that the Plan uses Local Coverage Determination (LCD) L35996 to support their denial. However, LCD L35996 is retired. Therefore, we cannot use LCD L35996 to substantiate our decision.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation of the medical branch blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of the medical branch blocks.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve CardioMEMS.

You asked the Plan to pre-approve CardioMEMS. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no 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 Plan was correct in denying the request to pre-approve CardioMEMS. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has ischemic cardiomyopathy and severe mitral insufficiency. NYHA Class III congestive heart failure (CHF) symptoms on guideline directed medical therapy which has been limited by hypotension (recently started on midodrine). Recent hospitalizations for CHF with persistent Class III symptoms. The enrollee meets ischemic cardiomyopathy and severe mitral insufficiency. NYHA Class III congestive heart failure symptoms on guideline directed medical therapy which has been limited by hypotension (recently started on midodrine). Recent hospitalizations for congestive heart failure with persistent Class III symptoms. There is already post marketing approval trial data published on its effectiveness as well. The enrollee meets the criteria for implantation (on appropriate guideline directed medical therapy but which is limited by hypotension in this instance, recent hospitalization for CHF and NYHA Class III CHF with persistent ongoing symptoms) the enrollee meets the medically necessity and reasonableness criteria for the requested use.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CardioMEMS have been met. Therefore, we decided that the Plan has to pre-approve CardioMEMS.

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 pre-approve a coombination sit to stand frame/table system.
You asked the Plan to pre-approve a coombination sit to stand frame/table system. You say that this device is medically necessary. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a coombination sit to stand frame/table system.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
You asked the Plan to pre-approve SNF care. You say that the enrollee must have a stay in subacute rehabilitation to ensure he regains strength and mobility. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve interspinous spacer device.

You asked the Plan to pre-approve interspinous spacer device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 interspinous spacer device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has spinal stenosis of the lumbar region. The interspinous spacer device is experimental. More research is needed to show safety and efficacy of the device. Therefore, the enrollee does not meet criteria for the requested 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 interspinous spacer device have not been met. Therefore, we decided that the Plan does not have to pre-approve interspinous spacer device.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve treatment with Udenyca (Q5111).
You asked the Plan to pre-approve Udenyca. You say that the requested treatment is a medical necessity for the
enrollee. The Plan denied your request. The Plan says that the use of the requested drug is not supported or
reasonable and necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Udenyca. Our reviewer says that the
requested drug is medically necessary for the enrollee. Our physician reviewer found that the requested use of
Udenyca is FDA-approved for the enrollee's diagnosis. The risk of neutropenic fever is greater than 20% given
prior chemotherapy and radiation coupled with current regimen of Carboplatin and Gemcitabine. The
documentation supports that the requested drug is safe and effective and otherwise reasonable and necessary
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 Udenyca have been met. Therefore, we decided that the Plan has to pre-approve
treatment with Udenyca (Q5111).
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 pre-approve a partial upper denture (D5213).
You asked the Plan to pre-approve the dental service. You say that you lost your partial upper denture. You say that you cannot wait for a new set of dentures until 2023. You also say that you cannot eat, and it is affecting you emotionally with depression. The Plan denied your request. The Plan says partial upper denture is covered once every 3 years. The Plan also says that the frequency limit has been reached.
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 the service is listed as covered, the frequency limit has been reached. The record shows that the Plan paid for a partial upper denture that you received on July 6, 2020. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation to go to court.
You asked the Plan to pre-approve routine transportation. You say that during the past year you did not use transportation services because the doctors you visit are close. You requested transportation to the Superior court, which is far away, and you suffer from glaucoma and cannot drive that distance. The Plan denied your request. The Plan says transportation to go to court is not included among the plan's other approved locations.
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 routine transportation to approved locations. Transportation to go to court is not included among the plan's other approved locations. We looked at your request, the records in the case file, and the rules. Therefore, we decided that the Plan does not have to pre-approve routine transportation to go to court.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build-up (D2950) for tooth # 20.
You asked the Plan to pre-approve the dental service. You say that the core build up is medically necessary.
The Plan denied your request. The Plan says core build up is not listed as a covered service.
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 core
build-up (D2950) for tooth # 20.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device (22869, 22870).
You asked the Plan to pre-approve a Vertiflex device. You say that you highly recommend this minimally invasive procedure when conservative treatment has failed and as a safer alternative to a laminectomy or spinal fusion procedure. The Plan denied your request. The Plan says this device is experimental and investigational as there are not enough studies to show that the use of the Vertiflex Superion device is better than regular spine surgery for the enrollee's problem.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion device (22869, 22870).