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

We decided that the Plan does not have to pre-approve treatment with amniotic fluid flow (Q4206).
You asked the Plan to pre-approve amniotic fluid flow. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested treatment is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve amniotic fluid flow. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that it was reported that the enrollee has tried and failed pain medication. Amniotic fluid flow (stem cell) was requested to be injected in the painful right shoulder. Based on currently available literature, stem cell treatment for chronic shoulder pain is not sufficiently supported with high quality evidence to justify this request. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of amniotic fluid flow have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with amniotic fluid flow (Q4206).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D5214).
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 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 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 (D5214).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Aranesp.
You asked the Plan to pre-approve Aranesp. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires
a trial of Retacrit before it will approve Aranesp.
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 Aranesp. Our reviewer says that the
enrollee does not meet the Medicare criteria for a step therapy exception for Aranesp. Our physician reviewer
found the enrollee has not tried and failed the Plan's preferred drug of Retacrit. The documentation submitted
does not show that this drug would likely be less effective and/or 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 Aranesp have not been met. Therefore, we decided that the Plan does not have
to pre-approve use of Aranesp.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system.
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 a power seat elevation system is non-covered. We looked at the file and Medicare rules. The services at issue are a power seat elevation system. These services are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the reline complete maxillary denture (D5750) provided March 1, 2021.
You asked the Plan to pay for the reline complete maxillary denture. You say that you were not aware this service would not be covered. The Plan denied your request. The Plan says the requested service is not among those covered under the supplemental 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 pay for the reline complete maxillary denture (D5750) provided March 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an abutment supported porcelain/ceramic crown (D6058), two pontics (D6245 x2), and four retainer crowns (D6740 x4).
You asked the Plan to pre-approve the abutment supported crown, pontics, and retainer crowns. You say that your dentist feels that a bridge is the best option for you. The Plan denied your request. The Plan says these services are not covered under your benefit plan.
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 an abutment supported porcelain/ceramic crown (D6058), two pontics (D6245 x2), and four retainer crowns (D6740 x4).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an office visit. You say that you would like approval for these services to be provided out-of-network. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 an office visit to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) continued stay provided from February 13, 2021, to March 14, 2021.
You asked the Plan to pay for the SNF services. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee returned to baseline and did not have any skilled needs on the dates of service in this case.
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 pay for the SNF services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) continued stay provided from February 13, 2021, to March 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IVIG.
You asked the Plan to pre-approve IVIG. You say that the enrollee has low IgG levels. The Plan denied your request. The Plan says there is a lack of follow-up information as requested.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There are no medical records in the case file to support medical necessity. Additional information was requested by the Plan but not received. Based on this information, we decided that Medicare rules for coverage of IVIG have not been met. Therefore, we decided that the Plan does not have to pre-approve IVIG.
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 SNF care. You say that SNF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a 91-year-old female congestive heart failure, chronic kidney disease, dementia and transient ischemic attack. In this case, there are no identifiable skilled nursing service needs and no identifiable skilled therapy service needs. In addition, the enrollee does not require skilled nursing or therapy services on a daily basis. Finally, the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pontics (D6245) for teeth #11 and 13, retainer crowns
(D6750) for teeth #12 and 14, and a porcelain crown (D2740) for tooth #20.
You asked the Plan to pre-approve the dental services. You say that tooth #20 is at risk of fracture. You say that
the enrollee has indicated he is unable to tolerate a partial. You also say that the partial would be unilateral and
therefore unstable. The Plan denied your request. The Plan says the requested 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 dental
services 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 dental services. Our reviewer says
that the requested bridge and crown are not medically necessary. Our physician reviewer found tooth #20 has a
minimal amount of missing tooth structure and does not appear to require a full coverage restoration.
Consideration of a full coverage restoration usually begins where 50% or more of the coronal structure missing
on a tooth. The reviewer found that given the lack of damage to the structure of #20, there is no necessity for a
crown. The reviewer found that the provided documentation shows decay at the margin of the abutment on
tooth #12. The reviewer found that it is not clear if there is significant decay, which could compromise the
stability of the new appliance. Without adequate radiographic views of tooth #12 abutment, it is not possible to
determine the extent of the marginal breakdown and if any additional treatment such as endodontics would be
required. Therefore, the reviewer found that the requested bridge is not medically reasonable or necessary
either.
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 dental services have not been met. Therefore, we decided that the Plan does
not have to pre-approve pontics (D6245) for teeth #11 and 13, retainer crowns (D6750) for teeth #12 and 14,
and a porcelain crown (D2740) for tooth #20.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).
You asked the Plan to pre-approve the total electric hospital bed. You say that the total electric hospital bed is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right sclerotherapy.
You asked the Plan to pre-approve injection of sclerosant; multiple incompetent veins (other than
telangiectasia), same leg (36471). You say that based on the enrollee's symptoms and imaging findings you
strongly disagree with the denial. The Plan denied your request. The Plan says they will approve right
endovenous ablation, mechanochemical, and right endovenous ablation, radiofrequency, but the enrollee does
not meet the coverage criteria for the requested right leg sclerotherapy.
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 injection of sclerosant; multiple
incompetent veins (other than telangiectasia), same leg (36471). Our reviewer says that the requested service is
not considered medically reasonable and necessary in this case. Our physician reviewer found the
documentation does not meet coverage criteria and does not support the medical necessity of the treatment in
question. Coverage criteria requires that for sclerotherapy to be medically necessary, the symptoms must be
severe enough to interfere with daily activities. In this case, the patient denies activity limiting symptoms.
Additionally, however, coverage requires that the patient must be significantly symptomatic despite
conservative efforts at least 6 weeks after addressing truncal reflux in the leg. At this point the patient has not
yet undergone the approved ablation - therefore it is not known if the additional sclerotherapy will be
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 injection of sclerosant; multiple incompetent veins (other than telangiectasia),
same leg (36471) have not been met. Therefore, we decided that the Plan does not have to pre-approve right
sclerotherapy.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on August 13, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment panels - except the basic lipid panel - for symptomatic patients with suspected or documented cardiovascular disease.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. This testing was ordered by an in-network provider. The file does not show that the plan provided notice that genetic testing would not be covered. Under Medicare rules, this means genetic testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for genetic testing provided on August 13, 2020.
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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a kidney biopsy.
You asked the Plan to pre-approve kidney biopsy. You say that your doctor wants to see what is wrong with
your kidneys before putting you on a new medication. The Plan denied your request. The Plan says the denial
of authorization for this service is correct, because your treating physician has not yet ordered this procedure.
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 kidney biopsy. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found a kidney biopsy cannot be approved without a doctor's order, which the Plan has not yet
received from your treating physician.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of kidney biopsy have not been met. Therefore, we decided that the Plan does not
have to pre-approve a kidney biopsy.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility visit provided by an out-of-network provider on August 18, 2020.
You asked the Plan to pay for the nursing facility visit. You say that the patient couldn't choose an in-network psychiatrist since no other provider was allowed in the facility. You say that it is not possible to request authorization before services are rendered and the claim should be processed for reimbursement. The Plan denied your request. The Plan says prior authorization was required but not obtained and in-network providers were available.
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 nursing facility visit provided by an out-of-network provider on August 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac joint injection (27096).
You asked the Plan to pre-approve a sacroiliac joint injection. You say that this should be covered. The Plan denied your request. The Plan says the requirements for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that if previous diagnostic or therapeutic sacroiliac joint injections relief have not effectively relieved the pain, defined as an initial pain relief greater than or equal to 75%, further injections would not be considered medically necessary. We looked at the file and Medicare rules. The records show that the previous injection provided only 50% to 60% pain relief. Based on this information, we decided that Medicare rules for coverage of a sacroiliac joint injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac joint injection (27096).