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

We decided that the Plan does not have to pre-approve myocardial perfusion imaging (78452).

You asked the Plan to pre-approve myocardial perfusion imaging. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered for the enrollee's condition

The Plan follows Medicare rules. Medicare rules say that routine stress testing in asymptomatic patients with abnormal prior stress imaging and/or obstructive or non-obstructive Coronary Artery Disease (CAD) without a revascularization procedure are considered not medically reasonable and 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 myocardial perfusion imaging. Our reviewer says that the requested testing is not medically necessary. Our physician reviewer found though his prior testing had shown some moderate inferior ischemia in 2019, the patient is currently asymptomatic with no chest or dyspnea symptoms and he walks regularly. He apparently had a cardiac catheterization in 2018 but no reported revascularization procedure at that time. He has not had an intercurrent cardiac event or revascularization procedure since his last nuclear imaging study in 2019 and is on guideline directed medical therapy.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of myocardial perfusion imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging (78452).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of a spinal cord stimulator.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says there has been no psychological evaluation.
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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria is not met, as there is no documentation of psychological evaluation. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve placement of a spinal cord stimulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for core build up (D2950 x 2), the retainer crowns (D6751 x 2), the pontic (D6241), and the unspecified preventive service (D1999) provided on December 24, 2020.
You asked the Plan to pay for the dental services. You say that you had your bridge removed due to a large cavity underneath. You say that you needed a replacement bridge. You say that your plan is supposed to cover amalgam restorations and resin composite restorations at 50%. You also say that you feel that the plan should pay at least 50% for these services as well. The Plan denied your request. The Plan says the services you received are not listed as 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 pay for core build up (D2950 x 2), the retainer crowns (D6751 x 2), the pontic (D6241), and the unspecified preventive service (D1999) provided on December 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional office visits with an out-of-network dermatologist.
You asked the Plan to pre-approve additional office visits. You say that the doctor has performed biopsies and removed cancerous lesions and advised he wanted to see you again in six months. You say that you do not have someone who can take you to the in-network providers. The Plan denied your request. The Plan says in-network providers are available.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve additional office visits. Our reviewer says that it is not medically necessary to continue care with the out-of-network provider. Our physician reviewer found that the Plan has in-network specialists that can meet the standard of care required for treatment of your condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional office visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional office visits with an out-of-network dermatologist.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar fusion surgery.
You asked the Plan to pre-approve the requested surgery. The Plan denied your request. The Plan says you
have not refrained from use of tobacco products for at least 6 weeks.
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 requested surgery. Our physician
reviewer found that smoking is a contraindication to fusion surgery. There is no documentation of a nicotine
test showing that the patient has stopped smoking. Therefore, the requested surgery in not medically reasonable
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 the requested surgery have not been met. Therefore, we decided that the Plan
does not have to pre-approve lumbar fusion surgery.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D4263, D4265).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not covered under the plan's 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
dental services (D4263, D4265).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal care services, per 15 minutes (T1019).
You asked the Plan to pre-approve the personal care services. You say that the services are medically
necessary. The Plan denied your request. The Plan says services with an indicator status of "I" are not valid for
Medicare purposes. The Plan also says that custodial care is not covered under any condition.
The Plan must follow Medicare rules. Medicare rules say that services with an indicator status of "I" are not
valid for Medicare purposes and therefore are not payable.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the personal care services have not been met. Therefore, we decided that the Plan does not have to
pre-approve personal care services, per 15 minutes (T1019).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet blocks for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that records show that the enrollee's pain has not been present for at least 3 months.
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are covered if the LCD criteria is 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 facet blocks are not medically reasonable and necessary for the enrollee. There is no documentation of adequate conservative measures over at least a 3 month period of time for back pain. Also, there is no documentation that the facet joints are the pain generators causing the back pain. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for facet blocks. 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 facet blocks for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home blood monitoring equipment (G0248, G0249) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve home blood monitoring equipment. You say that you have been using this equipment for 20 years and would like to continue. The Plan denied your request. The Plan says this is available 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 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 home blood monitoring equipment (G0248, G0249) to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan-Supartz.
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 covered.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be
brought to the office for administration. Since the medication does not represent an expense to the physician
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that
the Plan does not have to pre-approve Hyalgan-Supartz.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3.
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, Orthovisc and Monovisc. The
records do not show that the required drugs would be less effective or have adverse effects; therefore, the
Gelsyn-3 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 Gelsyn-3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve simple extractions (D7140 x 10), surgical extractions (D7210), removal of residual tooth roots (D7250 x 5), a frenectomy (D7961), and alveoloplasty (D7310 x 4) to be performed by an oral surgeon.

You asked the Plan to pre-approve the dental services. You say that your primary care physician (PCP) advised that this is dangerous for your life. The Plan denied your request. The Plan says the requested dental services are not covered. The Plan also says that services must be performed by a participating general dentist.

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, dental services must be performed by a participating general dentist. Dental services performed by an oral surgeon are not covered. Therefore, we decided that the Plan does not have to pre-approve simple extractions (D7140 x 10), surgical extractions (D7210), removal of residual tooth roots (D7250 x 5), a frenectomy (D7961), and alveoloplasty (D7310 x 4) to be performed by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.
You asked the Plan to pre-approve a portable ventilator. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 a portable ventilator. Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the ventilator at issue is medically necessary and reasonable for you. The records do not document that you have failed or would likely fail a bilevel positive airway pressure (BiPAP) device (E0471) with average volume-assured pressure support (AVAPS) technology. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (E0466).

You asked the Plan to pre-approve a home ventilator. You say that this requested item is medically necessary. The Plan denied your request. The Plan says the criteria for a home ventilator have not been met.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 a home ventilator. Our reviewer says that the requested item is not medically necessary and reasonable. Our physician reviewer found this patient has COPD, reportedly with hypercapnia, although this is not documented in the record. Notes indicate the patient is on Bilevel Positive Airway Pressure (BiPAP) device. There is no documentation of BiPAP failure. Medicare does not cover a home ventilator when used as BiPAP. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transforaminal epidural steroid injection (CPT code 64483) to be provided by an out-of-network provider.

You asked the Plan to pre-approve the injection. You say that the Plan sent you the names of two (2) in-network doctors and they are not a part of the clinic. The Plan denied your request. The Plan says there are in-network providers available who can supply the requested service.

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 transforaminal epidural steroid injection (CPT code 64483) to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and related accessories.

You asked the Plan to pre-approve a group 3 power wheelchair and related accessories. You say that this request 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 a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to:

1. A neurological condition;

2. Myopathy; or

3. Congenital skeletal deformity.

The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair and related accessories.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you are requesting
additional trips because you have several appointments due to your medical condition and 24 trips are not
enough. The Plan denied your request. The Plan says the request exceeds your benefit limit.
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.
We looked at your request, the records in the case file, and the rules. The requested amount exceeds the limit
listed by the Plan. Your 2021 ECO states that 24 one-way trips are covered per calendar year (limited to ground
transportation only). Therefore, we decided that the Plan does not have to pre-approve 12 additional routine
transportation trips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for unlisted multianalyte assay with algorithmic analysis (CPT code 81599) provided to the enrollee on May 22, 2020.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the submitted medical records confirm Melanoma on left shoulder. The Plan states the diagnosis of Melanoma is for 31 genes, it is unclear why a tiered approach is not appropriate for this 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 pay for the services. Our physician reviewer found the health plan's denial should be upheld. The enrollee is noted to have superficial cutaneous melanoma, along with several areas of basal cell skin carcinoma. The provided genetic test was not necessary to diagnose the patient or to determine that ongoing surveillance is needed. The provided test was not medically necessary or reasonable.

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 pay for unlisted multianalyte assay with algorithmic analysis (CPT code 81599) provided to the enrollee on May 22, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Keytruda.

You asked the Plan to pre-approve Keytruda. You say that if the enrollee stops Keytruda, the cancer will spread. The Plan denied your request. The Plan says that the clinical effectiveness of Keytruda beyond 24 months have not been demonstrated.

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 Keytruda. Our physician reviewer found that Keytruda is FDA-approved for the enrollee's diagnosis. The requested use is not listed as not indicated, not supported or not recommended in any of the compendia. Although discontinuing therapy at 2 years is an option, many clinicians treat until toxicity or progression for those that are tolerating pembrolizumab well. The documentation does support that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Keytruda have been met. Therefore, we decided that the Plan has to pre-approve Keytruda.

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.