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

We decided that the Plan does not have to pre-approve a procedure to implant an Optimizer Smart Implantable Pulse Generator (0408T).

You asked the Plan to pre-approve an Optimizer Smart Implantable Pulse Generator. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested procedure is experimental/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 an Optimizer Smart Implantable Pulse Generator. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that cardiac contractility modulation therapy with the Optimizer device is a relatively newer technology which is FDA approved but has limited randomized data showing modest benefit with regard to quality of life and walk time scores in patients already on maximal medical therapy. The enrollee has not had clinical documentation of optimization of medical therapy or blood pressure management to meet the indications for use of the device at present. The only clinical visit included in the records is a telehealth visit from March 2021 which describes uncontrolled blood pressure and medication changes but no follow-up of blood pressure, clinical visits, or examinations. Although at some point the enrollee may meet criteria for Optimizer therapy, at the current time the documentation of optimal medical therapy provided is insufficient to meet the indications for medical reasonableness and necessity for this 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 an Optimizer Smart Implantable Pulse Generator have not been met. Therefore, we decided that the Plan does not have to pre-approve a procedure to implant an Optimizer Smart Implantable Pulse Generator (0408T).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on October 2, 2020.

You asked the Plan to pay for genetic testing. You say that the services in question were clearly medically necessary. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the records provided are inadequate to support medical necessity.

The Plan must follow Medicare rules. Medicare rules say that the provider must furnish sufficient information to determine whether payment is due for a claim.

We looked at the file and Medicare rules. The records submitted do not include documentation of the lab results for this testing. The laboratory report lists "see attached" for the results of each test performed, but no attached results were submitted. Without this information, you have not furnished sufficient information to the Plan to support the medical necessity of these tests or justify payment of the tests as they have been billed on this claim. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided on October 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Tolvaptan 15 mg tablet.

You asked the Plan to pre-approve Tolvaptan. You say that the requested treatment is a medical necessity for
the enrollee. The Plan denied your request. The Plan says rules for self-administered drugs have not been met.

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 treatment with Tolvaptan 15
mg tablet.

Benefits for Tolvaptan 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve excision of excessive skin, including lipectomy.

You asked the Plan to pre-approve excision of excessive skin, including lipectomy. 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 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 excision of excessive skin, including lipectomy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee underwent reduction mammoplasty in February 2020. The medical records submitted are insufficient to determine whether the requested procedure is cosmetic or reconstructive in nature. The elements of the coverage determination are not satisfied. Therefore, the enrollee does not meet criteria for the requested services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of excision of excessive skin, including lipectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve excision of excessive skin, including lipectomy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).

You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested treatment is safe and effective. The Plan denied your request. The Plan says the procedure at issue is experimental/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 a Vertiflex procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested procedure is considered experimental/investigational and is not recommended by some learned specialty societies. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve at the in-network benefit level an outpatient office visit
to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve at the in-network benefit level an outpatient office visit. You say that these
services are medically necessary. The Plan denied your request. The Plan says they have in-network providers
available to provide for your medical needs.

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 at the in-network benefit level 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 at the in-network benefit level these items/services. Therefore, we decided that the Plan
does not have to pre-approve at the in-network benefit level an outpatient 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 pre-approve a skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee's care can be provided at an alternative level of care.

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 services. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at a maximal assist with bed mobility. She required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. She does not require skilled nursing or skilled therapy services on a daily basis. She does not meet severity of illness or intensity of service criteria for 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical procedure for isolation of tooth with rubber dam (D3910), canal preparation and fitting of preformed dowel or post (D3950), and drugs or medicaments dispensed in the office for home use (D9630).

You asked the Plan to pre-approve the surgical procedure, canal preparation and fitting, and drugs or medicaments. 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 a surgical procedure for isolation of tooth with rubber dam (D3910), canal preparation and fitting of preformed dowel or post (D3950), and drugs or medicaments dispensed in the office for home use (D9630).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on July 31, 2020.

You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg.

We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met.

Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed.

Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on July 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure (22899).

You asked the Plan to pre-approve an Intracept procedure. You say that the requested procedure is a medical necessity for you. The Plan denied your request. The Plan says the procedure at issue is experimental/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 an Intracept procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested procedure is considered an experimental/investigational procedure. 

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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure (22899).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electronic brachytherapy.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the clinical effectiveness of the requested service has not been demonstrated in peer-reviewed literature.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that there is a lack of demonstration of need for the requested service versus traditional external beam radiation, and statements from NCCN guidelines and medical societies that question its use. It would therefore not be considered to be furnished in accordance with accepted standards of 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve electronic brachytherapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine provided on September 28, 2020.

You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this is not a covered
benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The
Plan follows the same rules.

The records do not show that the enrollee has been injured or directly exposed to any illness related to the
vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on
September 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical tooth extraction (D7999).

You asked the Plan to pre-approve a surgical tooth extraction. You say that you are in pain and the service is
medically necessary. The Plan denied your request. The Plan says surgical extractions are not covered under
your 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 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
surgical tooth extraction (D7999).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex surgery.

You asked the Plan to pre-approve Vertiflex surgery. You say that this service is medically necessary. The Plan
denied your request. The Plan says Vertiflex surgery is not medically necessary in this case.

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 Vertiflex surgery. 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 remains experimental for the treatment of spinal stenosis. 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 Vertiflex surgery have not been met. Therefore, we decided that the Plan does
not have to pre-approve Vertiflex surgery.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa injections for both knees.

You asked the Plan to pre-approve the Euflexxa injections. You say that the requested injections are medically
necessary. The Plan denied your request. The Plan says there is no radiographic imaging that confirms the
enrollee's diagnosis of arthritis in their left knee. The Plan says there is no documentation indicating that you
have tried simple analgesics or non-medication-based therapy. The Plan also says that the requested injection is
not medically reasonable or 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 Euflexxa injections. Our reviewer
says that the Euflexxa injections for both knees are not medically necessary. Our physician reviewer found the
provided documentation does not include an x-ray for the enrollee's left knee. The reviewer found that there is
no documentation of oral pain medications for knee pain. Therefore, the reviewer found that the criteria for
bilateral knee viscosupplementation injection 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 the Euflexxa injections have not been met. Therefore, we decided that the Plan
does not have to pre-approve Euflexxa injections for both knees.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (93970, G0463, 99203, 99213) provided on October 26, 2020 to December 4, 2020.

You asked the Plan to pay for the physician services. You say that the services were medically necessary and should be covered. The Plan denied your request. The Plan says there were 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 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 these services. Therefore, we decided that the Plan does not have to pay for physician services (93970, G0463, 99203, 99213) provided on October
26, 2020 to December 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder test provided on June 17, 2020.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered test.

The Plan must follow Medicare rules. Medicare rules say that only the molecular bladder tests listed in the applicable LCD are covered.

We looked at the file and Medicare rules. The CxBladder test is not a covered molecular test per L35396. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder test provided on June 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7210), deep sedation/general anesthesia (D9222, D9223) and therapeutic parenteral drugs (D9610) provided on January 7, 2021.

You asked the Plan to pay for the dental services. You say that the Plan should cover these services, as you were unable to use a contracted provider in this urgent situation. The Plan denied your request. The Plan says they have agreed to cover these services up to $600. However, the charges over this amount exceed what is covered under this 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 items or services are requested in excess of the allowance provided under this benefit. Therefore, we decided that the Plan does not have to pay an additional amount for the extraction (D7210), deep sedation/general anesthesia (D9222, D9223) and therapeutic parenteral drugs (D9610) provided on January 7, 2021.