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

We decided that the Plan does not have to pre-approve CT scan of the abdomen and pelvis for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says there is insufficient clinical information to approve the requested study.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the last visit of 3/11/21 revealed no fever or abdominal tenderness. All labs were normal. The only reference to abdominal symptoms was listed as "BS very high". The assumption is that BS refers to bowel sounds but that is an insufficient reason for CT of the abdomen and pelvis. It is noted there are no plain film studies of the abdomen to determine if there is any evidence of ileus or mechanical obstruction; both being very unlikely in light of the lack of other clinical findings. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the abdomen and pelvis for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet block injections.
You asked the Plan to pre-approve facet block injections. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that Thermal Medial Branch Radiofrequency Neurotomy is covered when specific criteria are met. 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 facet block injections. Our reviewer says that the services are not medically necessary. Our physician reviewer found the fact that MBB were performed after radiofrequency ablation (RFA) suggests that the RFA did not produce sustained pain relief. Therefore, the request does not meet coverage criteria and is considered 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 facet block injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet block injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hearing exam.

You asked the Plan to waive the copayment for the hearing exam. You say that this was your free annual hearing test, and you did not know you would the audiologist was not in the Plan's hearing network. The Plan denied your request. The Plan says 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 each in-network Medicare-covered hearing exam to determine if you need medical treatment for a hearing condition.

You have been asked to pay a $40 copayment for the hearing exam. The hearing exam falls within the "Hearing services - Medicare-covered" benefit category. The medical record shows a diagnosis of sensorineural hearing loss which makes the hearing exam medical in nature. 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 hearing exam.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT).
You asked the Plan to pre-approve PBRT. You say that this is medically necessary. The Plan denied your
request. The Plan says the requested treatment is not the standard of care.
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 PBRT. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found to date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than
intensity-modulated radiation therapy or image-guided radiation therapy. The generally accepted standard of
care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to
patients.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to
pre-approve proton beam radiation therapy (PBRT).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zoledronic Acid (J3489).

You asked the Plan to pre-approve Zoledronic Acid. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, 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 Zoledronic Acid. Our reviewer says that the medication is not medically necessary. Our physician reviewer found although zometa is FDA approved for the treatment of skeletal metastases from solid tumors such as breast cancer, no uncorrected hypocalcemia is permitted by the health plan. No calcium level is provided. The service is not reasonable or 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 Zoledronic Acid have not been met. Therefore, we decided that the Plan does not have to pre-approve Zoledronic Acid (J3489).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee does not have a history of osteoporotic fracture, and has not tried and failed Zoledronic acid.

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 Prolia. Our physician reviewer found that the enrollee has a history of osteoporosis. The Plan requires a trial of Zoledronic acid, and have a history of osteoporotic acid before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the plan's requirements would likely be less effective 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
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 these services are medically necessary. The Plan denied your request. The Plan says that your needs can be met at a lower level of care.
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for knee pain after a fall. You were discharged to a skilled nursing facility on July 30, 2020 and then was transferred to a long-term care facility on August 15, 2020. You received physical and occupational therapy throughout these care periods. You were discharged home on March 7, 2021 and have been receiving physical therapy at home. You report ongoing weakness and trouble getting around. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for FoundationOne CDx provided on May 8, 2020.
You asked the Plan to pay for FoundationOne CDx. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the records sent in for review do not show that results of the testing will make a difference in the treatment.
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 pay for FoundationOne CDx. 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 staging provided for rationale for the use of next-generation sequencing, such as with FoundationOne, for this 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 FoundationOne CDx have not been met. Therefore, we decided that the Plan does not have to pay for FoundationOne CDx provided on May 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 20, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory work. You say that the service was rendered in good faith as requested by the provider. The Plan denied your request. The Plan says no prior authorization was obtained
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 medical services provided on October 20, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided on September 29, 2020.
You asked the Plan to waive the deductible for the office visit. You say that the provider is an in-network provider. The Plan denied your request. The Plan says 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. Your contract with the Plan says that there is a $500 deductible that applies towards out-of-network office visits. The office visit you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible that applies towards out-of-network office visits. The record shows the provider is out-of-network. This cost sharing is a contractual obligation that had not been met at the time the office visit was received on September 29, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on September 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Doxepin.

You asked the Plan to pre-approve Doxepin. The Plan denied your request. The Plan says this is not covered under the enrollee's Part B plan.

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 Doxepin.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower/bathtub transfer bench.
You asked the Plan to pre-approve the bench. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a shower/bathtub transfer bench.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a seat lift mechanism (E0627) provided from a provider not certified with Medicare.

You asked the Plan to pay for a seat lift mechanism. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this provider is not certified with Medicare; therefore, no payment can be made.

The Plan must follow Medicare rules. Medicare rules say that no provider shall receive payment if they are not enrolled in the Medicare program.

We looked at the file and Medicare rules. The file indicates that the provider that supplied the seat lift mechanism is not certified with Medicare. Based on this information, we decided that Medicare rules for coverage of a seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pay for a seat lift mechanism (E0627) provided from a provider not certified with Medicare.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
You asked the Plan to provide a therapeutic continuous glucose monitor. You say that you need a CGM to control your blood sugar while mobile. The Plan denied your request. The Plan says criteria is not met for a CGM.
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 perform blood glucose testing at least four times per day or 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 provide a therapeutic continuous glucose monitor.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care provided to the enrollee from March 8, 2021, forward.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care provided to the enrollee from March 8, 2021, forward.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient admission for an approved shoulder
surgery.
You asked the Plan to pre-approve the inpatient admission. You say that it is felt that this inpatient surgery is
needed. The Plan denied your request. The Plan says the surgery has been approved as outpatient. Conversion
to inpatient status can be considered if the need arises after surgery.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the inpatient admission. Our reviewer
says that the documentation does not support that the criteria for inpatient admission are met in this case. Our
physician reviewer found the enrollee is medically stable and has been provided medical clearance to undergo
this elective procedure. The planned procedures are not listed as Inpatient-Only. The review has determined
that the record does not show that the admitting physician reasonably expects that the patient's necessary
hospital care will span two midnights.
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 inpatient admission have not been met. Therefore, we decided that the Plan
does not have to pre-approve acute inpatient admission for an approved shoulder surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and each additional
intraoral periapical x-ray provided on August 11, 2020.
You asked the Plan to pay for the intraoral periapical x-rays. You say that you did not realize that the dental
services had to take place with a provider from the state you reside in. The Plan denied your request. The Plan says these services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the first
intraoral periapical x-ray and each additional intraoral periapical x-ray provided on August 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve left breast implant removal.

You asked the Plan to pre-approve removal of intact breast implant, left breast (19328). You say that the enrollee needs this surgery. The Plan denied your request. The Plan says the records do not show problems with the left breast implant.

The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.

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 removal of intact breast implant, left breast (19328). Our reviewer says that the surgery is not medically necessary. Our reviewer found the medical documentation does not support that removal of the left breast implant is medically necessary in this case. For a patient who has had an implant(s) placed for reconstructive or cosmetic purposes, Medicare considers treatment of any one or more of the following conditions to be medically necessary:
Broken or failed implant 
Infection
Implant extrusion 
Siliconoma or granuloma 
Interference with diagnosis of breast cancer 
Painful capsular contracture with disfigurement
The documentation does not support that criteria for removal of the left breast implant have been met in this case.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of removal of intact breast implant, left breast (19328) have not been met. Therefore, we decided that the Plan does not have to pre-approve left breast implant removal.