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

We decided that the Plan does not have to pre-approve destruction of lower or sacral spinal facet joint nerves using imaging guidance.
You asked the Plan to pre-approve destruction of lower or sacral spinal facet joint nerves using imaging guidance. 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 for each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months. 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 destruction of lower or sacral spinal facet joint nerves using imaging guidance. Our reviewer says that the services are not medically necessary. Our physician reviewer found the request exceeds utilization criteria. Therefore, the request is considered not medically reasonable 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 destruction of lower or sacral spinal facet joint nerves using imaging guidance
have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction of lower or
sacral spinal facet joint nerves using imaging guidance.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 30 physical therapy (PT) visits.
You asked the Plan to pre-approve 30 PT visits. 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 must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 30 PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found documentation does not support the need for requested ongoing
physical therapy services. The enrollee with her knee pain has had the benefit of therapy for 23 sessions and made progress with inconsistent compliance. Based on these two factors, the requested additional therapy visits are not medically necessary for the enrollee's knee pain. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 30 PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 30 physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve selective internal radiation therapy (SIRT) to be rendered by an out-of-network (OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested 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 care that cannot be provided by network providers. You are not a network provider with the Plan. The Plan has network providers available who can provide the service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve selective internal radiation therapy (SIRT) to be rendered by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve auto-emersion therapy system (E1399).
You asked the Plan to pre-approve auto-emersion therapy system. You say that you are high risk for infection and skin breakdown. You need this bed to help relieve pressure from your wounds. The Plan denied your request. The Plan says this item has deluxe features that are not medical in nature which basically serves comfort or convenience functions and does not constitute medical equipment.
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 auto-emersion therapy system (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital clinic visit provided on March 16, 2021.
You asked the Plan to pay for the hospital clinic visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 did not pre-approve the services 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 a hospital clinic visit provided on March 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702).
You asked the Plan to pre-approve the orthotic device. You say that this enrollee has exhausted the other
available therapies and has not regained meaningful use of her left upper extremity. The Plan denied your
request. The Plan says this item is considered experimental and investigational. There is insufficient evidence
of its effectiveness in those with stroke and hemiparesis.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. The rules also say that experimental and investigational devices are not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to preapprove
the MyoPro Motion G orthotic device (L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture and a partial lower denture.
You asked the Plan to pre-approve a partial upper denture and a partial lower denture. You say that the requested items are necessary. The Plan denied your request. The Plan says the benefit has been exhausted.
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 complete dentures (upper and lower) or partial dentures (upper and lower) once every five years. 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 a partial upper denture and a partial lower denture have not been met. Specifically, you received dentures on December 21, 2018. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture and a partial lower denture.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Desvenlafax and Pennsaid.
You asked the Plan to pre-approve Desvenlafax and Pennsaid. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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 Desvenlafax and Pennsaid.
Benefits for Desvenlafax and Pennsaid 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transmitter for a continuous glucose monitor (CGM).

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 transmitter described by code A9277 is for a non-therapeutic CGM. 

We looked at the file and Medicare rules. The requested transmitter is for a non-therapeutic CGM. These services are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a transmitter for a continuous glucose monitor (CGM).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation is needed. The Plan denied your request. The Plan says the benefit has been exhausted.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way transportation trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to pre-approve an MRI of the lumbar spine. We decided that the Plan does not have to pre-approve the services to be performed at an out-of-network facility.
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the services are necessary. The Plan says that based on the documentation provided, coverage criteria has not been met.
We decided that the Plan has to pre-approve an MRI of the lumbar spine. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Part C Plan was correct in denying the request to pre-approve an MRI of the lumbar spine. Our reviewer says that the requested service is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has multiple medical issues including diabetes, multiple sclerosis (MS) and complex back pain with radicular symptoms. An MRI is indicated given all these issues and is needed to attempt to separate mechanical causes of her lower extremity symptoms versus peripheral neuropathy versus diabetic neuropathy.
Therefore, we decided that the Plan has to pre-approve an MRI of the lumbar spine.
We also decided that the Plan does not have to pre-approve the services to be performed at an out-of-network facility. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found based the records provided do not show evidence that the requested scan including conscious sedation cannot be performed at an in-network facility.
Therefore, we decided that the Plan does not have to pre-approve the services to be performed at an out-of-network facility.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from August 27, 2021 and forward.

You asked the Plan to pre-approve the continuation of inpatient mental health care from August 27, 2021 and forward. You say that the continuation of inpatient mental health care from August 27, 2021 and forward is medically necessary. The Plan denied your request. The Plan says the continuation of inpatient mental health care from August 27, 2021 and forward is not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 continuation of inpatient mental health care from August 27, 2021 and forward. Our reviewer says that the continuation of inpatient mental health care from August 27, 2021 and forward is not medically necessary. Our physician reviewer found this enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. I am unable to find an individualized treatment plan however the entire record is not present. It appears that the services were supervised and evaluated by a physician. Based upon review of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health facility beyond the date in question of August 27, 2021 and forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. 

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 continuation of inpatient mental health care from August 27, 2021 and forward have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from August 27, 2021 and forward.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Formoterol.
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 medically necessary.
The Plan must follow Medicare rules. The rules say that a drugs covered under Medicare Part B are not eligible for Part D tier exceptions. We looked at the file and Medicare rules. The requested services are a tier exception for Formoterol. This drug is covered by Part B and is not eligible for a Part D tier exception. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Formoterol
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) additional PT visits (CPT code 97164).
You asked the Plan to pre-approve the PT visits. You say that you are in pain and this has been helping you a lot. The Plan denied your request. The Plan says the documentation provided is not supportive that the unique and sophisticated skills of a physical therapist are required to continue to treat this condition. The Plan states you did not have any documented objective improvement with ongoing therapy.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 the PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found documents do not support that the requested therapy is effective for your condition. 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 PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eight (8) additional PT visits (CPT code 97164).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for genetic testing (81162) provided December 21, 2020.
You asked the Plan to waive the coinsurance for the genetic testing. You say that the cost-sharing should be waived. The Plan denied your request. The Plan says the correct coinsurance was applied.
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 20% coinsurance for laboratory tests. You have been asked to pay 20% of the allowable amount of $1,824.88, for a total of $364.98, for the genetic testing. the genetic testing falls within the laboratory tests benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for genetic testing (81162) provided December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the prolonged evaluation and management service before and/or after direct patient care; first hour (99358), prolonged evaluation and management service before and/or after direct patient care; each additional 30 minutes (99359), and the telephone evaluation and management service (99443) rendered by the out-of-network (OON) provider on February 26, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

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 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 services 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 the prolonged evaluation and management service before and/or after direct patient care; first hour (99358), prolonged evaluation and management service before and/or after direct patient care; each additional 30 minutes (99359), and the telephone evaluation and management service (99443) rendered by the out-of-network (OON) provider on February 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy represented by dental code D3330.

You asked the Plan to pre-approve dental code D3330. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says dental code D3330 is not covered under the Plan's supplemental dental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, dental code D3330 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy represented by dental code D3330.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine venipuncture (36415) rendered by the out-of-network (OON) provider on April 19, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the routine venipuncture (36415) rendered by the out-of-network (OON) provider on April 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre for 1 year.
You asked the Plan to pre-approve a Freestyle Libre for 1 year. You say that the services are necessary. The Plan denied your request. The Plan says a Freestyle Libre has been approved for 6 months. One-year coverage does not meet the criteria.
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 a Freestyle Libre for 1 year. Our reviewer says that the services are not medically necessary. Our physician reviewer found LCD L33822 states that every 6 months following the initial prescription of a continuous glucose monitor, the treating practitioner must have an in-person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan. A duration of 1 year is not supported 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 a Freestyle Libre for 1 year have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre for 1 year.