Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to the practice.
You asked the Plan to pre-approve these services. You say that you are on a fixed income and would like noninvasive surgery. 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 submitted records show that you have back pain. The requested procedure is considered experimental in nature. More research is needed to show its safety and effectiveness. The procedure is 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 a referral to this practice.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a low vision evaluation to be provided by the Provider. You asked the Plan to pre-approve the low vision evaluation. You say that the enrollee has macular degeneration in both eyes and needs to have a low vision evaluation by the provider to determine the most appropriate optical and non-optical aids, devices and strategies to help her to be more independent. The Plan denied your request. The Plan says that Medicare usually does not cover the cost of any device or aid that uses a lens, including low vision devices that help to maximize the remaining vision for someone who has experienced impaired vision.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollee's needs.
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 low vision evaluation. Our reviewer says that the low vision evaluation to be provided by the provider is medically reasonable and necessary. Our physician reviewer found that a low vision evaluation is performed by an ophthalmologist or optometrist who specializes in low vision, to determine whether special low vision optical devices, better lighting, large print reading materials, or other types of training, such as vision rehabilitation services, can help a person use his or her functional vision more effectively. The enrollee is already being treated by a retinal specialist for neovascular, age-related macular degeneration with active choroidal neovascularization (wet AMD) in both eyes. Avastin injections have been administered in the right eye. No treatment was advised for the left eye on July 30, 2019 "given very long standing condition with sub-optimal response." Our physician reviewer fount that the care being offered by the Plan is not equivalent to the requested low vision evaluation. The Plan has suggested that the enrollee see a general ophthalmologist. However, she is already under the care of a retinal specialist. The enrollee has significantly altered vision, and a low vision evaluation is not offered in the Plan's network. The available documentation supports that the requested low vision evaluation is an urgently needed service which is not provided within the Plan's network.

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 low vision evaluation have been met. Therefore, we decided that the Plan has to pre-approve a low vision evaluation to be provided at providers center.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the discission of secondary membranous cataract
(66821).
You asked the Plan to pre-approve the discission of secondary membranous cataract. You say that this service
is medically necessary. The Plan denied your request. The Plan says the records do not indicate member is
having trouble seeing after cataract surgery
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 discission of secondary
membranous cataract. Our reviewer says that the documentation is insufficient to demonstrate that requested
YAG capsulotomy is medically necessary for the enrollee in this case. Our physician reviewer found while the
enrollee reported glare and halos, the documentation does not support visual loss, such as a visual acuity of
20/30 or worse.
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 discission of secondary membranous cataract have not been met. Therefore,
we decided that the Plan does not have to pre-approve the discission of secondary membranous cataract
(66821).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the periodontal scaling and root planing -four or more teeth per quadrant (code D4341) on the upper right, upper left and lower left quadrants and the periodontal scaling and root planing -one to three teeth per quadrant (code D4342) on the upper right quadrant to be provided. You asked the Plan to pre-approve the periodontal scaling and root planing (D4341, D4342). You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary. 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. The Plan covers the periodontal scaling and root planing (D4341, D4342) when the services are medically necessary and reasonable. 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 periodontal scaling and root planing (D4341, D4342). Our reviewer says that the services are not shown to be medically necessary. Our physician reviewer found that bone loss levels cannot be seen due to the poor quality of the x-rays and there must be signs of bone loss for treatment.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the periodontal scaling and root planing (D4341, D4342) have not been met.Therefore, we decided that the Plan does not have to pre-approve the periodontal scaling and root planing -four or more teeth per quadrant (code D4341) on the upper right, upper left and lower left quadrants and the periodontal scaling and root planing -one to three teeth per quadrant (code D4342) on the upper right quadrant to be provided.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not have to pre-approvea low dose computed tomography (CT) scan for the enrollee.You asked the Plan to pre-approvethe requested CT scan. You say that the enrollee meets the screening criteria.The Plan denied your request. The Plan says therecords do not show that the enrollee is between 55 and 80 years of age.The Plan must follow Medicare rules. Medicare rules say that a low dose CT scans for lung cancer screening is only covered under certain medical indications. We looked at the file, and Medicare rules. The records provided shows that at the time of request, the enrollee was 51 years old. Medicare only covers the requested testing for ages 55-77 years old. Based on this information, we decided that Medicare rules for coverage of the requested CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approvea low dose computed tomography (CT) scan..
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out of network provider.You asked the Plan to pre-approve the services. You say that the services are necessary.The Plan denied your request. The Plan says out-of-network services are not covered.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 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. We found no exception that would require the Plan to pre-approve these services.Therefore, we decided that the Plan does not have to pre-approve medical services to be provided by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve post-kidney transplant services to be provided at the medical center. You asked the Plan to pre-approve the post-kidney transplant services. You say that you would like to continue your kidney transplant follow-up with the provider at the medical center because the provider has been your transplant doctor since 2006. The Plan denied your request. The Plan says you may only see non-preferred providers if the service is not available in the preferred network or is an emergency. 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 pre-approved care.We looked at the file and the rules. The provider is not a network provider with the Plan. The file shows that the Plan has an in-network provider available to perform the necessary tests you require.We found no exception that would require the Plan to pre-approve the requested services. Therefore, we decided that the Plan does not have to pre-approve post-kidney transplant services to be provided at the medical center.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the immediate upper and lower dentures (D5130, D5140) to be provided. You asked the Plan to pre-approve the immediate upper and lower dentures (D5130, D5140). You say that due to medical history of multiple health conditions, it is medically necessary to have dentures. You say she needs to be able to eat nutritious meals to maintain adequate health. The Plan denied your request. The Plan says the services are not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the immediate upper and lower dentures (D5130, D5140) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the immediate upper and lower dentures (D5130, D5140) to be provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve adjustable knee extension/flexion device (E1810) to be provided.You asked the Plan to pre-approve adjustable knee extension/flexion device. You say that early application/use of your device can reduce time and cost associates with range of motion rehabilitation.The Plan denied your request. The Plan says based on the records this request is 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 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 adjustable knee extension/flexion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided the adjustable knee extension/flexion device (E1810) is not medically reasonable and necessary for this enrollee at this time based on the fact that the device is not indicated for use in a case where the contracture is chronic.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of adjustable knee extension/flexion device have not been met.Therefore, we decided that the Plan does not have to pre-approveadjustable knee extension/flexion device (E1810).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvephysician's ophthalmology services to be provided by the provider forthe enrollee.You asked the Plan to pre-approvethe physician's ophthalmology services. You say that the in-network provider has not been able to help your mother with her macular degeneration. You say your mother's eyesight is deteriorating rapidly and she is in need ofservices.The Plan denied your request. The Plan says generally, the enrollee must receive care from a network provider. Care will be directed outside of the primary network only if it has been determined that the care cannot be provided in-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 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. We found no exception that would require the Plan to pre-approve the requested services.Therefore, we decided that the Plan does not have to pre-approvephysician's ophthalmology services to be provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider. You asked the Plan to pre-approve an office visit. You say that you would like this referral approved.The Plan denied your request. The Plan says there are in-network providers available for you to see. 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 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 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 medical services to be provided by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upper and lower dentures to be provided. You asked the Plan to pre-approve upper and lower dentures. You say that the enrollee is in need of upper and lower dentures based on medical need. You also say that she is a diabetic and needs the proper nutrition. The Plan denied your request. The Plan says the enrollee received partial dentures less than 60 months ago. The Plan also says the enrollee's benefit has been exhausted and the enrollee is not eligible for upper and lower dentures at this time .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 replacement of removable and fixed prostheses is covered only if the existing prostheses were inserted at least 60 months prior to the replacement. The record shows that you received partial dentures on October 2, 2017 and your removable and fixed prostheses benefit is now exhausted. Therefore, we decided that the Plan does not have to pre-approve upper and lower dentures to be provided.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed Tomography (CT) of the Abdomen and Pelvis (74177). You asked the Plan to pre-approve the CT scan. You say that the CT scan should be approved.The Plan denied your request. The Plan says coverage criteria has not been met. The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 the CT scan. Our reviewer says that the requested CT scan is not medically necessary. Our physician reviewer found the enrollee had a one-week history of lower abdominal pain. There was no fever, no vomiting, no nausea. No other relevant history was submitted. There was left lower quadrant tenderness. There was no documented guarding or rebound.  Laboratory studies were performed but the results were not submitted. There was no documented concern for an acute abdominal process.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 CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approve Computed Tomography (CT) of the Abdomen and Pelvis (74177).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ophthalmology consultation with a tertiary level provider. You asked the Plan to pre-approve the tertiary level ophthalmology consultation. You say that it is felt that this service should be provided. The Plan denied your request. The Plan says although you have received tertiary level care for some conditions, there is no evidence that your glaucoma requires a tertiary level of care. A non-tertiary glaucoma specialist is available and can meet your needs. 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 tertiary level ophthalmology consultation. Our reviewer says that the requested tertiary level consult is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 68-year-old man was evaluated by a contracted tertiary retinal specialist for a serous retinal detachment of the right eye. His history is also notable for cataract extraction with intraocular lens insertion. The enrollee was suspected to have glaucoma of both eyes, and a glaucoma service consultation was advised. The documentation in the case file does not support that the enrollee's condition requires a tertiary level glaucoma specialist.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 tertiary level ophthalmology consultation have not been met.Therefore, we decided that the Plan does not have to pre-approve an ophthalmology consultation with a tertiary level provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the Thoracic Spine (72146).
You asked the Plan to pre-approve the MRI. You say that you have had chronic back pain and the pain has been significant. The Plan denied your request. The Plan says that the MRI does not meet coverage criteria.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that coverage criteria has been met. Our physician reviewer found the enrollee has a lengthy history of back pain including surgery. Current treatment includes long term use of medications that have side effects. Multiple treatment options have been trialed. The MRI is reasonable and 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the Thoracic Spine (72146).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Psychotropic Assay testing. You asked the Plan to pre-approve these services. You say that you need the testing to see what medication will help your condition. The Plan denied your request. The Plan says the testing is not medically necessary. The Plan must follow Medicare rules. Medicare rules say that testing is covered when specific criteria are met. 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 testing is not medically necessary. Our physician reviewer found the submitted records show that you have a diagnosis of recurrent moderate major depressive disorder and anxiety. You have been on multiple medications in the past. The records do not show that the testing is being ordered by a licensed psychiatrist or neuropsychiatrist, as required by the Medicare rules. The testing is therefore not reasonable or medically necessary at this time. 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 Psychotropic Assay testing. The Plan references LCD L34519 in their determination; however, this LCD does not provide coverage criteria for the specific testing at issue and was not used in the MAXIMUS determination.