Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean interspinous spacer (22869).You asked the Plan to pre-approvethe interspinous spacer. You say that the device placement is medically necessary.The Plan denied your request. The Plan says the requested interspinous spacer is considered investigation at this time and is not covered.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 interspinous spacer. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the evidence based medical guidelines and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. The Superion indirect lumbar decompression device would not be considered the standard of care for the enrollee's medical 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 interspinous spacer have not been met.Therefore, we decided that the Plan does not have to pre-approvean interspinous spacer (22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services can be safely received in other settings, for example: a skilled nursing facility or home with home health services.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for cervical spine surgery. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee oes not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home A1c monitor.
You asked the Plan to pre-approve these services. You say that a blood glucose monitor is covered; therefore, the A1c meter is covered. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that A1c testing more than every three months in a controlled diabetic patient is not necessary. We looked at the file and Medicare rules. The file does not show that you require home A1c testing more frequently than every three months. The testing can be appropriately performed in the physician's office. 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 home A1c monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network
provider on June 17, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
approved in advance.
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
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 medical services provided to the enrollee by an out-of-network
provider on June 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pontic (D6245) for tooth # 12.You asked the Plan to pre-approvethe pontic. You say that the enrollee needs these services.The Plan denied your request. The Plan says the pontic is not listed as a covered service. The Plan also says that if a dental item or service is not listed in the benefit chart then it is 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. The Customer Handbook clearly states that if a dental item or service is not listed in the benefit chart then it is not covered.Therefore, we decided that the Plan does not have to pre-approvea pontic (D6245) for tooth # 12.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea referral to an out-of-network oncologist.You asked the Planto pre-approvethe referral. You say that this is medically necessary.The Plandenied your request. The Plansaysyou are covered for an oncology consultation, but you will need to see a contracted provider.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plandoes not haveto pre-approvea referral to an out-of-network oncologis
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Actemra administered intravenously.
You asked the Plan to pre-approve Actemra administered intravenously. You say that the requested Actemra to
be administered intravenously is medically necessary. The Plan denied your request. The Plan says the
requested Actemra to be administered intravenously is not medically 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 Actemra administered intravenously.
Our reviewer says that the requested Actemra to be administered intravenously is not medically necessary. Our
physician reviewer found the review indicates that the enrollee is with a diagnosis of temporal arteritis. The
member has started Actemra weekly since May 2020 as subcutaneous injections, however; treatment was
complicated by injection site reactions. The provider is seeking authorization to treat with intravenous Actemra
at this time. Intravenous Actemra 4 mg per kg q 4 weeks is the subject of this review.
The U.S. Food and Drug Administration today expanded the approved use of subcutaneous Actemra
(tocilizumab) to treat adults with giant cell arteritis. This new indication provides the first FDA-approved
therapy, specific to this type of vasculitis. The recommended dose of Actemra for adult patients with GCA is
162 mg given once every week as a subcutaneous injection, in combination with a tapering course of
glucocorticoids. A dose of 162 mg given once every other week as a subcutaneous injection, in combination
with a tapering course of glucocorticoids, may be prescribed based on clinical considerations. Actemra can be
used alone following discontinuation of glucocorticoids. Actemra subcutaneous formulation is not intended for
intravenous administration. The review has determined that the documentation supports that Actemra is
medically reasonable and necessary for the enrollee. The requested IV use of the medication is not indicated.
The documentation does not support that IV Actemra is safe and effective 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 Actemra administered intravenously have not been met. Therefore, we decided
that the Plan does not have to pre-approve Actemra administered intravenously.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveincontinence supplies.You asked the Plan to pre-approveincontinence supplies. The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approveincontinence supplies
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedental medication (D9630).You asked the Plan to pre-approvedental medication. You say that the enrollee needs this.The Plan denied your request. The Plan says this is 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 pre-approvedental medication (D9630).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forconsultation (D9310) and the extraction (D7210) provided on September 29, 2020.You asked the Plan to pay forthe dental services. You say that the tooth in question needed to be extracted. You say that it was infected and hanging by the roots. You also say that it caused you pain when chewing.The Plan denied your request. The Plan says the consultation is not listed as a covered service. The Plan also saysthat there is a 50% coinsurance for surgical extractions.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 consultation is not among those covered under this benefit. Additionally, there is a 50% coinsurance for extractions. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage.Therefore, we decided that the Plan does not have to pay forconsultation (D9310) and the extraction (D7210) provided on September 29, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDurolane injections (J7318).You asked the Plan to pre-approveDurolane. You say that Durolane is medically necessary.The Plan denied your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be considered.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 Durolane. Our reviewer says that Durolane is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drugs. The record shows no reason why the plan preferred drugs would be unsafe or ineffective for this 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 Durolane have not been met.Therefore, we decided that the Plan does not have to pre-approveDurolane injections (J7318)
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinterspinousspacers (22869, 22870).You asked the Plan to pre-approveinterspinous spacers. You say that the requested items/services are medically necessary.The Plan denied your request. The Plan says rules for pre-approval have 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 interspinous spacers. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the spacers are experimental. More research is needed to show safety and efficacy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of interspinous spacers have not been met.Therefore, we decided that the Plan does not have to pre-approveinterspinous spacers (22869, 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe vision exam you received on August 5, 2020.You asked the Plan to pay forthe vision exam. The Plan denied your request. The Plan says the claim was processed correctly.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to a $75 limit.We looked at the file and the Plan's rules. The records show that the Plan paid $75 toward the eye exams. You are responsible for any amount over the $75 benefit limit.Therefore, we decided that the Plan does not have to pay forthe vision exam you received on August 5, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pre-approve the Omniseq Comprehensive Panel.
You asked the Plan to pre-approve the Omniseq Comprehensive Panel. You say that you would like reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says that this panel is considered repeat testing.
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 Omniseq Comprehensive Panel. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the value of next generation sequencing (NGS) to predict candidates for specific mutation-driven treatment holds promise. Patients with inflammatory and metastatic breast cancers benefit from NGS to identify markers that may indicate benefit from targeted treatment or clinical trials. Omniseq offers NGS as patient has exhausted standard therapies and has metastatic breast cancer. Genetic testing is not the same as NGS. 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 Omniseq Comprehensive Panel have been met. Therefore, we decided that the Plan has to pre-approve the Omniseq Comprehensive Panel.
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 pay for the laboratory services provided on April 1, 2020, by an out-of-network provider.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider and the services were not urgent or emergent, nor were they approved in advance.
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 laboratory services provided on April 1, 2020, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvean expandable controller (E2377, harness (E2313) and electronic connection (E2311).You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysyou have no weakness in the right upper limb and is independent with using joystick.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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that you require other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). You  do not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices),other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. Youhave sufficient right upper extremity strength and function that he should be able to control any power options through their own individual switches.
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 services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvean expandable controller (E2377, harness (E2313) and electronic connection (E2311).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the lumbar spine with contrast (72132).
You asked the Plan to pre-approve this service. You say that a CT scan of the lumbar spine is medically necessary for the enrollee. The Plan denied your request. The Plan says this service is not medically necessary.
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 this service. Our reviewer says that this service is not medically necessary for the enrollee. Our physician reviewer found that the enrollee was hospitalized on December 21, 2020 with back pain and weakness. Higher-level imaging was ordered, the results of which have not been submitted for review. What transpired during the hospitalization is unknown, as neither those nor subsequent follow-up records have been submitted for review. As such, the documentation does not support that additional CT imaging of the enrollee's lower back is currently necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the lumbar spine with contrast (72132).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, panoramic xrays,
and first intraoral periapical x-ray provided on June 22, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation, panoramic x-rays, and first intraoral
periapical x-ray. You say that you were not advised that the x-rays that were performed would not be covered.
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
problem focused limited oral evaluation, panoramic x-rays, and first intraoral periapical x-ray provided on June
22, 2020.