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

We decided that the Plan does not have to pre-approve a Transthoracic Echocardiogram (TTE) (93306).You asked the Plan to pre-approvethe TTE. You say that the echocardiogram is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.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 TTE. Our reviewer says that the transthoracic echocardiogram is not medically necessary. Our physician reviewer found the patient has known atrial dysrhythmia and pacemaker but no other documented cardiac disease, no documented cardiac symptoms, no documented cardiovascular physical exam abnormalities and no documented pacemaker malfunction. In this circumstance the documentation does not support the medical necessity for an echocardiogram.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 TTE have not been met.Therefore, we decided that the Plan does not have to pre-approvea Transthoracic Echocardiogram (TTE) (93306).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Iron Sucrose Injections (J1756)You asked the Plan to pre-approve the Iron Sucrose Injections. You say that the requested drug is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.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 Iron Sucrose Injections. Our reviewer says that the injections are not medically necessary. Our physician reviewer found submitted documentation documentation does not support renal or other chronic disease.  The enrollee was noted to have a hemoglobin level of 9.5 and hematocrit of 32.2. There is no documentation of malabsorption syndromes or failure or oral iron supplementation.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 Iron Sucrose Injections have not been met.Therefore, we decided that the Plan does not have to pre-approve Iron Sucrose Injections (J1756)
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal laminectomy surgery at the L3-4 level.You asked the Plan to pre-approve spinal surgery. Yousay that the enrollee needs this surgery to regain her walking ability and for overall health and safety.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee's pain level is 3 out of 10 and surgery is not medically necessary under this condition.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 spinal surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no severe stenosis shown on Computed Tomography (CT) scan. There was not relief with an epidural steroid injection. The enrollee's current pain score is only 3 out of 10. Therefore, the enrollee's symptoms are not severe enough for surgery 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 spinal surgery have not been met.Therefore, we decided that the Plan does not have to pre-approvespinal laminectomy surgery at the L3-4 level.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 39 hours a week of home health attendant care.
You asked the Plan to pre-approve 39 hours a week of home health attendant care. You say that you need attendant care and your hours should not be reduced. The Plan denied your request. The Plan says your level of function now meets criteria for only 31 hours a week.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 39 hours a week of home health attendant care. Our reviewer says that the documentation does not reveal that the requested services are be reasonable and necessary to the treatment of the patient's illness or injury. Our physician reviewer found a Patient Assessment Tool on August 2, 2019 indicates that the patient needs help with bathing, dressing, feeding, grooming, hair/skin care, toileting, transfers/walking, cleaning, meal prep, shopping, and managing medications. The assessment noted 31 hours per week was necessary. The documentation does not reveal extenuating factors that would necessitate the full 39 hours of services therefore this request 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 39 hours a week of home health attendant care have not been met. Therefore, we decided that the Plan does not have to pre-approve 39 hours a week of home health attendant care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton treatment complex for the enrollee.You asked the Plan to pre-approvethe treatment. You say that this is medically necessary.The Plan denied your request. The Plan says the need was not met, as other treatment is available.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 treatment. Our reviewer says that the requested treatment is not considered medically reasonable and necessary in this case. Our physician reviewer found proton therapy is not experimental, but rather is simply another means of delivering radiation, and has been in use for the treatment of oncology patients for decades. There are dosimetric advantages to using proton therapy over IMRT in many situations, though proton therapy offers a clinically meaningful benefit only in select situations. It is reasonable to use proton therapy as it is an accepted approach, though it is not necessarily superior to IMRT outside of compelling, plausible rationales suggesting need for proton therapy. IMRT and VMAT are accepted, efficacious and safe means to treat with radiation. It is not plausible that proton therapy is needed to provide a clinically significant benefit and therefore it would not be "furnished in accordance with accepted standards."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 treatment have not been met.Therefore, we decided that the Plandoes not haveto pre-approve proton treatment complex for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider. You asked the Plan to pre-approve dermatology services. You say that the services you will provide will prevent further visits. The Plan denied your request. The Plan says there are in-network providers available for the same 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 pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator. You asked the Plan to pre-approvea portable oxygen concentrator. You say that because of your condition it is very difficult to carry a portable oxygen tank which inhibits your mobility outside of the house.The Plan denied your request. The Plan says the flow rate required exceeds the capacity of a portable oxygen concentrator and you have not tried small tanks. The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep.  We looked at the file and Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. You have a portable oxygen system that meets your in-home needs. The item at issue in this appeal is for use outsideof the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Based on this information, we decided that Medicare rules for coverage of a portable oxygen concentrator have not been met.Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve cervical epidural steroid injection (CESI) at C7-T1.
You asked the Plan to pre-approve the CESI. You say that the enrollee would benefit from this treatment. The Plan denied your request. The Plan says that there is insufficient documentation of conservative treatment and there are no findings at the level at which treatment is requested.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CESI. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic neck pain with radiation to the arms. He is on gabapentin for pain and NSAIDs have not helped. He had a prior trial of PT and does a home exercise program. The MRI shows multi-level degenerative disc disease and neuroforaminal stenosis. As the enrollee has cervical radiculopathy with demonstrated foraminal stenosis, the CESI is considered medically necessary. It is to be done at level C7-T1 as all CESIs are done at these lower levels for safety reasons. 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 CESI have been met. Therefore, we decided that the Plan has to pre-approve cervical epidural steroid injection (CESI) at C7-T1.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by out of network provider, "the out of network doctor".You asked the Plan to pre-approvea second opinion. You say that the providers in-network lack the requisite level of experience that you need for your diagnosis.The Plan denied your request. The Plan says there are in-network providers 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available, "in network doctors", 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-approvethe medical services to be provided by out of network provider, "the out of network doctor".
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous stabilization device for the enrollee.
You asked the Plan to pre-approve the device. You say that the enrollee has failed more than six months of conservative approaches to treatment at this time. The Plan denied your request. The Plan says there is a lack of evidence to support that these devices are as safe and effective as the gold standard of decompression.
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 device. Our reviewer says that the requested device not considered medically reasonable and necessary in this case. Our physician reviewer found this device is considered experimental, and more research is needed. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous stabilization device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

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

We decided that the Plan does not have to pre-approve Botox injections.You asked the Plan to pre-approve the injections. You say that nothing has ever helped you for 13 years.The Plan denied your request. The Plan says medical studies haven't proven that this drug is helpful for treatment of your health problem.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 injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided the Botox injections in this case are not medically reasonable and necessary. The Medicare-approved compendia do not contain any citation to support the use of Botox injections for pelvic pain related to pudendal neuralgia.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 injections have not been met.Therefore, we decided that the Plan does not have to pre-approve Botox injections.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Cologuard screening test.You asked the Plan to pre-approveCologuard test. You say that the enrollee is at risk due to 1 family member with colon cancer, so the plan should reconsider coverage.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee has a family history of colorectal cancer and therefore does not meet Medicare coverage criteria for Cologuard test.The Plan must follow Medicare rules. Medicare rules say that the Cologuard test is not covered for enrollees who have a personal or family history of colorectal cancers. We looked at the file and Medicare rules. The enrollee has a family history of colorectal cancer, and therefore does not meet the Medicare coverage criteria for the Cologuard test. Based on this information, we decided that Medicare rules for coverage of Cologuard test have not been met.Therefore, we decided that the Plan does not have to pre-approvea Cologuard screening test.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedental fillings, and a root canal.You asked the Plan to pre-approvethe dental services. You say that your dentist gave you a written prescription for the dental services that you need.The Plan denied your request. The Plan says root canals are not listed as a covered service. The Plan also says that there is no order from your treating dentist for dental fillings.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, root canals are not among those covered under this benefit. Additionally, there is no record that your dentist ordered fillings to be done.Therefore, we decided that the Plan does not have to pre-approvedental fillings, and a root canal.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a physical exam.You asked the Plan to pre-approvethese services. You say that the physical is required by the Department of Transportation to get your CDL license.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that Medicare does not cover services furnished, paid for, or authorized by government entities.We looked at the file and Medicare rules. The services at issue are being requested as a requirement for the Department of Transportation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approve a physical exam
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upper and lower dentures (D5213, D5214) to be provided.You asked the Plan to pre-approve the upper and lower dentures (D5213, D5214). You say that the dentures are necessary because you have trouble eating, tooth aches, sore gums, and a broken tooth. The Plan denied your request. The Plan says the services are not covered benefits.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 upper and lower dentures (D5213, D5214) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the upper and lower dentures (D5213, D5214) to be provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve consultation for low vision assessment to be provided
by out of network provider.
You asked the Plan to pre-approve the consultation. You say that you are appealing this denial as the requested
exam is not routinely completed by ophthalmology or optometry providers. The Plan denied your request. The
Plan says enrollee's must receive their medical services from an in-network provider. The plan says if an
enrollee requires medical care that Medicare requires the plan to cover and there are no in-network providers
who can provide the care then the enrollee can receive the care from an out-of-network provider. The plan has
confirmed that Optometry specialists are 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 pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
consultation for low vision assessment to be provided by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upper and lower dentures (D5110, D5120) to be provided by the provider. You asked the Plan to pre-approve the upper and lower dentures (D5110, D5120). You say that the services are needed. The Plan denied your request. The Plan says these services are not covered under your 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 upper and lower dentures (D5110, D5120) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the upper and lower dentures (D5110, D5120) to be provided by the provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Otezla for the enrollee. You asked the Plan to pre-approve Otezla. The Plan denied your request. The Plan says that this medication is not covered under Part B. 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 Otezla for the enrollee. Benefits for Otezlamay be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.