Persius/hicric huggingface dataset:
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 Synvisc One. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy exception criteria.
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 Synvisc One. Our reviewer says that the Plan requires a trial of drug(s) Orthovisc and Monovisc before they will approve the requested drug, Synvisc One. Based on the medical records provided the member has not tried and failed the required drugs. Our physician reviewer found there is no indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the member. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc One.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device (22869, 22870).

You asked the Plan to pre-approve the Vertiflex device. You say that you believe that the minimally invasive implantation of a posterior interspinous process spacer device is the most appropriate treatment for this enrollee and this choice meets the requirements as reasonable and medically necessary. The Plan denied your request. The Plan says there is not enough studies of the Vertiflex Superion device to show it is safe and effective.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device (22869, 22870).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion 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 patients who have this procedure have significant improvement in their quality of life and ability to perform acts of daily living pain free. The Plan denied your request. The Plan says there are not enough studies to show the Vertiflex Superion Device is safe and effective.

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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of the enrollee's height, weight, or body mass index. Detailed documentation is not evident regarding evaluation of scoliosis of the lumbar spine with no documentation of the Cobb angle. There is no discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in this patient. 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 Vertiflex Superion Device 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 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 a Vertiflex Superion device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a temporary crown (D2799) and a core buildup procedure (D2950).

You asked the Plan to pre-approve the temporary crown and core buildup. You say that these services are necessary. The Plan denied your request. The Plan says these services are not covered by Medicare or by the Plan's supplemental dental 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 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 temporary crown (D2799) and a core buildup procedure (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the simple extraction and three surgical extractions provided on December 3, 2020.
You asked the Plan to pay for the extractions. The Plan denied your request. The Plan says your annual maximum of $1,000 was met for the 2020 calendar year.
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 Plan offers a max allowance amount of $1,000 per year for supplemental comprehensive dental services. The contract says that you are responsible for all costs over and above the allowance amount. The record shows that you met the annual maximum benefit on December 31, 2020 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the simple extraction and three surgical extractions provided on December 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3 (J7328).
You asked the Plan to pre-approve Gelsyn-3. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.
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 Gelsyn-3. Our reviewer says that Gelsyn-3 is not medically reasonable and necessary for the enrollee. Our physician reviewer found based on the medical records provided the enrollee has tried and failed Orthovisc, but has not tried and failed Monovisc. Our physician reviewer also found that the enrollee has tried and failed Orthovisc, but there is no indication that Monovisc 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 Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have to pre-approve Gelsyn-3 (J7328).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a darbepoetin alfa injection.
You asked the Plan to pre-approve darbepoetin alfa injection. You say that you have anemia due to your chemotherapy for leukemia. You also say that these treatments are vital to your health. The Plan denied your request. The Plan says the requested drug is not FDA approved to treat your condition.
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 darbepoetin alfa injection. Our reviewer says that the requested injection is not medically necessary. Our physician reviewer found the requested use of darbepoetin alfa injection is not FDA-approved for your diagnosis. The reviewer found that the requested use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The reviewer found that the requested use is not listed as not indicated, not supported or not recommended in any of the compendia. Therefore, the reviewer found that the requested injection is not 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 darbepoetin alfa injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a darbepoetin alfa injection.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for physical therapy.

You asked the Plan to pre-approve the referral. You say that you are not satisfied with the therapy that is being offered in-plan. The Plan denied your request. The Plan says the requested provider is out-of-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral out-of-network for physical therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on November 25, 2020 by an out of network provider.
You asked the Plan to pay for the office visit. You say that your physician sent you to this facility for a COVID test. The Plan denied your request. The Plan says the test was paid for but the out-of-network office visit was not urgent nor approved in advance.
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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit provided on November 25, 2020 by an out of network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 36 out of network physician visits.
You asked the Plan to pre-approve 44 out of network physician visits. You say that it is necessary to use this provider due to the language barrier. The Plan denied your request. The Plan says while 8 visits have been approved to allow transition back into the network, the remaining visits are not approved. Maximus overturned the Plans denial for continuity of care. The Plan requested a reopen and stated that you left the Plan as of December 31, 2020 and this care could have been provided in network.
The Plan is correct in this case. The provider in this case is not a network provider with the Plan. The Plan authorized enough transition visits through the course of the enrollment with the Plan. Had Maximus been aware that you were going to disenroll at the end of the year, requested visits would not have been appropriate. Therefore, we decided that the Plan does not have to pre-approve the remaining 36 out of network physician visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.

You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that the request is medically necessary. The Plan denied your request. The Plan says you are not on 3 or more insulin injections per day or a continuous insulin infusion pump.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retreatment of previous root canal therapy (D3346) and canal preparation and fitting (D3950) for tooth 11.

You asked the Plan to pre-approve the root canal services. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are not covered by Medicare or by the Plan's supplemental dental 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve retreatment of previous root canal therapy (D3346) and canal preparation and fitting (D3950) for tooth 11.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous passive motion exercise device for the enrollee.

You asked the Plan to pre-approve the machine. You say that this is needed due to hand stiffness. The Plan denied your request. The Plan says this is not being used for the knee.

The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have received total knee replacement surgery.

You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-approve a continuous passive motion exercise device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve panniculectomy and abdominoplasty for the enrollee.
You asked the Plan to pre-approve panniculectomy and abdominoplasty. You say that this surgery is medically
necessary. The Plan denied your request. The Plan says The Plan states Medicare coverage criteria are not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct criteria.
Our Medial Director looked at the case file and the reopen request. At issue is coverage for panniculectomy.
The Maximus Physician Reviewer determined that the surgery met criteria. The Plan argues that there is no
complaint or physical findings of dermatitis related to the abdominal panniculus. The Plan notes a history of a
vesicular rash on the palmar aspects of her hands, but nothing related to the abdomen. The Plan states the
Plastic Surgeon notes state the enrollee has recurrent intertrigo dermatitis over a three-month period of time
and is refractory to appropriate medication therapy. However, the Plan notes is no supportive documentation in
the medical records of this statement and no photos. Our Medical Director has concluded that the Plan is
correct in this case. The medical records in the case file do not support that the enrollee's panniculus causes
chronic intertrigo (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or chafing)
that consistently recurs over three months while receiving appropriate medical therapy or remains refractory to
appropriate medical therapy over a period of three months. Medicare coverage criteria are not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of panniculectomy and abdominoplasty have not been met. Therefore, we decided
that the Plan does not have to pre-approve panniculectomy and abdominoplasty for the enrollee.
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 this is medically necessary. The Plan denied your request. The Plan says the enrollee's needs could be met in another setting.
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. Our physician reviewer found based on the medical records provided, the complexity of the patient's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is concern that the patient will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to his cognitive status and decreased endurance. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on
December 10, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that you do not know why
insurance is not paying for the service. You say you should not be responsible for the copayment. The Plan
denied your request. The Plan says the Explanations of Benefits were reprocessed, and you have been asked to
pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40
copayment for provider and professional services at an in-network specialist's office.
You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls
within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the copayment for the specialist office visit provided on December 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prefabricated abutments (D6056) and abutment supported crowns (D6058) for tooth #12 and tooth #5.
You asked the Plan to pre-approve the abutments and crowns. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are not covered by Medicare or by the Plan's supplemental dental 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 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 (D6056) and abutment supported crowns (D6058) for tooth #12 and tooth #5.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for full face mask used with positive airway pressure device (A7030) provided October 25, 2020, by a provider not certified with Medicare.
You asked the Plan to pay for full face mask used with positive airway pressure device. You say that this service was medically necessary. The Plan denied your request. The Plan says coverage cannot be provided for items purchased from a provider not certified with Medicare.
The Plan must follow Medicare rules. Medicare rules say that payment can only be made to providers certified with Medicare. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of full face mask used with positive airway pressure device have not been met. Therefore, we decided that the Plan does not have to pay for full face mask used with positive airway pressure device (A7030) provided October 25, 2020, by a provider not certified with Medicare.