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

We decided that the Plan does not have to provide Ozurdex (J7312),
You asked the Plan to provide Ozurdex (J7312). You say that you want to treat the enrollee with this drug. The Plan denied your request. The Plan says the off-label use of this drug for the enrollee's condition is not medically accepted per Medicare rules.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 provide Ozurdex (J7312). Our reviewer says that the drug is not reasonable and medically necessary. Our physician reviewer found treatment with Ozurdex implant is not medically necessary in this case. Although dexamethasone implant is safe and effective for some macular diseases, in this case it would not be recommended. There is evidence in the medical literature that adjunctive treatment of intravitreal Lucentis with dexamethasone implant for macular degeneration does not improve outcomes for the disease and subjects the patient to undue risk of side effects from the steroid. The health plan denial of coverage and argument is valid. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ozurdex (J7312) have not been met. Therefore, we decided that the Plan does not have to provide Ozurdex (J7312),
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced foot and rotational unit K3 foot.

You asked the Plan to pre-approve an advanced foot and rotational unit K3 foot. You say that this enrollee was very active and independent before the amputation and expresses a strong desire to return to his active lifestyle and independence. The Plan denied your request. The Plan says the request for K3 foot does not meet Medicare criteria as reasonable and necessary as the enrollee is currently not a K3 ambulator.

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 an advanced foot and rotational unit K3 foot. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records show that enrollee needs the aid of supportive devices such as crutches, canes, wheelchairs, and walker. This is inconsistent with K3 ambulation. No objective clinical information is provided to support that member cannot use a K2 foot. The review has determined that the requested advanced foot and rotational unit K3 foot is 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 an advanced foot and rotational unit K3 foot have not been met. Therefore, we decided that the Plan does not have to pre-approve an advanced foot and rotational unit K3 foot.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prefabricated abutments for teeth 15 and 18.

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.

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
prefabricated abutments for teeth 15 and 18.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Monovisc for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise 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 the drug. Our reviewer says that the requested drug is medically reasonable and necessary. Our physician reviewer found the documentation indicates that the enrollee has tried and failed previous cortisone injections, exercises and medical therapy. The x-rays demonstrate significant arthritis in the medical compartment. The review has determined that regarding viscosupplementaiton therapy, the literature states that that intra-articular injection of cross-linked and non-cross-linked HA decreases symptoms of osteoarthritis and can provide significant improvements in pain on activity, pain at rest, and function, with few adverse events. Trials that involved cross-linked HA showed much greater pooled estimates of efficacy than the trials involving non-cross-linked HA. The overall conclusion was that intra-articular injection of cross-linked or non-cross-linked decreased the symptoms of osteoarthritis of the knee. Significant improvements in pain were noted, and cross-linked HA had greater pooled mean differences. The review has determined that the documentation supports that the requested Monovisc injection is medically reasonable and necessary for the enrollee. The documentation supports that the requested Monovisc injeciton is safe and effective 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 the drug have been met. Therefore, we decided that the Plan has to pre-approve Monovisc for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for 4 additional units of health behavior intervention provided on December 9, 2020.
You asked the Plan to pay for health behavior intervention, group (2 or more patients), face-to-face; each additional 15 minutes (List separately in addition to code for primary service) (96165-59). You say that the modifier was used on the claim to show this procedure was separate and distinct. The Plan denied your request. The Plan says that units have been exceeded.
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. The medical records provided show that the service billed with the -59 modifier is a distinct procedural service. The records show 4 additional units of health behavior intervention occurred. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have been met. Therefore, we decided that the Plan has to pay for 4 additional units of health behavior intervention provided on December 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar interspinous device.
You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (22870). You say that the enrollee has failed conservative approaches to treatment. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational
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 insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (22870). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the vertiflex 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 insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (22870) have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar interspinous device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 11, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 11, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from September 11, 2020, through September 15, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically necessary as the treatment provided was required and needed and could not be done at a lower level of care. The Plan denied your request. The Plan says that the inpatient admission was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee is a 71-year-old woman with hypertension, hyperlipidemia and hypothyroidism who was admitted for supraventricular tachycardia and elevated troponin. The Medicare rules indicate that inpatient admission is generally appropriate if the enrollee requires medically necessary hospital care that is expected to span 2 or more midnights, then inpatient admission is generally appropriate. "Span 2 or more midnights" includes time spent in the ED and/or observation, as well as time spent at another hospital prior to transfer to the current facility. The decision to admit as an inpatient should generally be based on the treating physician's reasonable expectation of a length of stay spanning 2 or more midnights, taking into account complex medical factors that must be documented in the medical record. In this case, the enrollee was administered antiarrhythmic medication, heparin intravenously, an electrophysiological studies and ablation. The documented an anticipated stay of greater than two days. The admitting physician's expectation was reasonable based upon the presenting symptoms and clinical scenario as documented. The elements of the coverage rule are satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from September 11, 2020, through
September 15, 2020.
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 the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says placement in a skilled nursing facility, at this time, is not necessary, particularly
given the ongoing COVID-19 risk.
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 the admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled
nursing or skilled therapy needs. You are ambulating household distances and tending to ADLs with minimal
supervision. Daily skilled services are not required to establish a maintenance program or to prevent
deterioration of your condition. Your care needs at this point are considered custodial, and as a practical matter,
can be provided at a lower level of care, such as home, assisted living, or long-term 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 the admission 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 an interspinous device.
You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). You say that the enrollee has tried and failed conservative treatment. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational.
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 insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). 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 insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete replacement of shoulder joint (CPT code 23472) and anchoring of the biceps tendon (CPT Code 23430), for the enrollee.
You asked the Plan to pre-approve the services. You say that the magnetic resonance imaging (MRI) was reviewed demonstrating degenerative tearing of rotator cuff despite report. You state regardless of whether the rotator cuff is intact, reverse total shoulder arthroplasty is indicated in this enrollee's age group with the extent of arthritic changes that are present. You state the enrollee has limited range of motion (ROM) of their shoulder and significant weakness on physical exam. You state the enrollee has significant pain that is impacting their quality of life. The Plan denied your request. The Plan says the services are not 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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. Furthermore, MRI demonstrates supraspinatus tendinosis and infraspinatus tendinosis and subscapularis tendinosis, subacromial subdeltoid bursal fluid; long head biceps tendinosis; glenohumeral joint osteoarthritis and labral degeneration; acromioclavicular joint osteoarthropathy and early subacromial spur. Guidelines do not support the requested procedure in the absence of a massive/irreparable cuff tear or in the absence of failure of conservative measures. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for complete replacement of shoulder joint (23472) and anchoring of the biceps tendon (23430) 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve complete replacement of shoulder joint (CPT code 23472) and anchoring of the biceps tendon (CPT Code 23430), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjustable bed provided on July 3, 2020 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 the adjustable bed provided on July 3, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myrbetriq.
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 self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Myrbetriq.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network cardiovascular specialist consultation
(99213) to be provided by an OON provider.

You asked the Plan to pre-approve the cardiovascular specialist consultation. You say that the consultation is
medically necessary. The Plan denied your request. The Plan says there are in-network providers that can
provide the consultation at issue.

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 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 an out-ofnetwork
cardiovascular specialist consultation (99213) to be provided by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services, rural area, transport furnished by a volunteer ambulance company (A0432) provided on October 26, 2020.
You asked the Plan to pay for the paramedic intercept services. You say that the service provided was an essential health service necessary to try to save your mother's life. It is beyond your comprehension why this basic, essential service is not covered by the plan. The Plan denied your request. The Plan says paramedic intercept services are non-covered services.
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished under a contract with a qualified basic life support (BLS), the provision of medically necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow the volunteer ambulance company to bill for the transport or BLS services.
The Plan has confirmed that there is no contract with the volunteer ambulance company that provided the transport services. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services, rural area, transport furnished by a volunteer ambulance company (A0432) provided on October 26, 2020.