Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6245) and two retainer crowns (D6740 x2).

You asked the Plan to pre-approve the pontic and retainer crowns. You say that you would like to appeal these
services. The Plan denied your request. The Plan says these services 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
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
pontic (D6245) and two retainer crowns (D6740 x2).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sedation for pain injections.
You asked the Plan to pre-approve the sedation. 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 sedation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee does not have an indication for Monitored Anesthesia Care, and as such, sedation is not recommended by several authorities. The request 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 sedation have not been met. Therefore, we decided that the Plan does not have to pre-approve sedation for pain injections.
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 these services are medically necessary. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower level of care.
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. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 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. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Mvasi (Q5107).
You asked the Plan to pre-approve Mvasi. You say that you would like the Plan to reconsider their denial. The
Plan denied your request. The Plan says this drug is not being prescribed for a medically accepted indication.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is
due and the amount of payment.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of these services have not been met. Specifically, there were no medical records provided in this case.
Without the medical records, we cannot review to see if the services were urgent/emergent or medically
necessary. Therefore, we decided that the Plan does not have to pre-approve Mvasi (Q5107).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient angioplasty and stent placement for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of imaging that shows obstruction of 50% or greater.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is described as having likely true angina. There is very limited description with respect to the enrollee's leg symptoms, and impact on quality of life. It can be noted that the enrollee is non-compliant and continues to smoke. There is no mention of recommendations for conservative treatment. The enrollee was previously a no-show for a similar procedure last year. The documentation provided is conspicuous in that there is no pulse examination included. There are also no non-invasive vascular testing results provided. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve outpatient angioplasty and stent placement for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have right knee osteoarthritis. You have not tried and failed the Plan's required drugs, Euflexxa, Durolane, Supartz-FX and Gelsyn-3. The records do not show that the required drugs would be less effective or have adverse effects; therefore, Synvisc-One is not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you appear to be at or near your baseline level of function.

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 services. Our physician reviewer found that you are at a contact guard assist level for bed mobility, and standby assist for sitting. You do not have documented skilled nursing or therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve test strips over the quantity limit of twice a day testing.
You asked the Plan to pre-approve additional test strips. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that additional test strips 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 additional test strips. Our reviewer says that the documentation does not support that the requested items are medically reasonable or necessary. Our physician reviewer found the documentation does not address the reason that greater than usual quantities of test strips are needed. The responses from the prescribing provider clinic does not support the need for the specific quantity of supplies that exceeds the usual utilization amounts. Therefore, you do not meet criteria for the requested additional test strips. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve test strips over the quantity limit of twice a day testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on October 26, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has opted out of Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee on October 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an above knee test socket (L5624) and an above knee acrylic socket (L5631).
You asked the Plan to pre-approve an above knee test socket and an above knee acrylic socket. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested items are not reasonable and necessary.
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 case file and Medicare rules. Medicare rules state that an above knee test socket and an above knee acrylic socket are not reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of an above knee test socket and an above knee acrylic socket have not been met. Therefore, we decided that the Plan does not have to pre-approve an above knee test socket (L5624) and an above knee acrylic socket (L5631).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic manipulative treatment (98941) mechanical traction (97012) provided on December 22, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the chiropractic services. You say that you are filing an earnest appeal concerning the denial of the doctor's rendered services. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for chiropractic manipulative treatment (98941) mechanical traction (97012) provided on December 22, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the revascularization services coded 37233 provided on October 28, 2020.
You asked the Plan to pay for the revascularization services. 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 supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 37233 is revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure). We find that CPT code 37233 is not supported in the medical record. Specifically, the operative report did not include documentation to meet the guidelines of an open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with atherectomy, includes angioplasty within the same vessel; therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the revascularization services have not been met. Therefore, we decided that the Plan does not have to pay for the revascularization services coded 37233 provided on October 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device.
You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.
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 insertion of a Vertiflex device. Our reviewer says that the requested 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 that it is safe and effective. 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 insertion of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a history of bilateral knee osteoarthritis. He has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not show that the required drugs would be contraindicated or less effective; therefore, the Euflexxa is not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane (J7318).
You asked the Plan to pre-approve Durolane (J7318). You say that the enrollee has tried other drugs for the knee pain. The Plan denied your request. The Plan says the health plan states the enrollee has not first tried and had a contraindication or intolerance to Orthovisc and Monovisc.
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 Durolane (J7318). Our reviewer says that the drug is not reasonable and medically necessary. Our physician reviewer found in this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane (J7318) have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane (J7318).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inversion table (E1399).
You asked the Plan to pre-approve an inversion table. You say that the requested item was recommended by
your physician. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and documentation of medical necessity.
The record does not contain a valid physician order or relevant medical records which support medical
necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain
the necessary documentation without success. Therefore, we decided that the Plan does not have to pre-approve
an inversion table (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
You asked the Plan to pre-approve these services. You say that you have poor quality of life. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have chronic low back, hip, and SI joint pain. The requested RFA of the SI joint is considered experimental in nature due to wide variation in effectiveness. The services are therefore not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stab phlebectomy of varicose veins and unlisted
procedure, vascular surgery.
You asked the Plan to pre-approve Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions
(37765), Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions (37766), and Unlisted
procedure, vascular surgery (37799). You say that the enrollee needs these procedures. The Plan denied your
request. The Plan says the request does not meet the LCD criteria.
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 Stab phlebectomy of varicose veins and
unlisted procedure, vascular surgery. Our reviewer says that the documentation does not meet coverage criteria
and does not support the medical necessity of the treatment in question. Our physician reviewer found at the
patient's most recent documented visit the patient was noted to be feeling well in October 2020. Pedal pulses
were documented as palpable. Lower extremity venous duplex demonstrated successful endovenous treatment
of the right greater saphenous vein without superficial reflux bilaterally. The plan was for continued use of the
graduated compression stockings. Since that visit, there has been no further medical record documentation of a
patient visit including a physical examination or recent duplex. There is no documentation in the medical
record of a plan for phlebectomy. Agree with health plan determination.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions (37765),
Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions (37766), and Unlisted procedure,
vascular surgery (37799) have been met. Therefore, we decided that the Plan does not have to pre-approve Stab
phlebectomy of varicose veins and unlisted procedure, vascular surgery.