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

We decided that the Plan has to pre-approve the Sinuplasty.
You asked the Plan to pre-approve the Sinuplasty. You say that you would like reconsideration because you have had chronic sinusitis which triggers migraines and unwanted weight loss. The Plan denied your request. The Plan says that the requested service is not medically necessary.
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 Sinuplasty. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the documentation indicates that the enrollee has yearly episodes of difficult to treat acute sinusitis. The episodes have also ben accompanied by confirmatory CT scan findings. The CT scan demonstrates anatomic abnormality of the maxillary ostia. 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 Sinuplasty have been met. Therefore, we decided that the Plan has to pre-approve the Sinuplasty.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
You asked the Plan to pre-approve the Vertiflex Superion Spacer. You say that you would like reconsideration because the member demonstrates to be a good candidate because no radiographic evidence of instability, no remarkable scoliosis or severe osteoporosis. The Plan denied your request. The Plan says review of the current medical literature indicates that this service is considered experimental and 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 the Vertiflex Superion Spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this 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 Vertiflex Superion Spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy.
You asked the Plan to pre-approve proton beam therapy. You say that the requested proton beam therapy is medically necessary. The Plan denied your request. The Plan says the requested proton beam therapy is 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 proton beam therapy. Our reviewer says that the requested proton beam therapy is not medically necessary. Our physician reviewer found radiation therapy can be considered medically necessary for select patients with relapsed diffuse large B-cell lymphoma (DLBCL). Proton therapy could be justified when the need is sufficiently supported but I cannot determine that proton therapy is medically necessary, in the absence of a compelling dosimetric (or evidence based) rationale, when other potentially equally efficacious forms of radiotherapy are available. Routine use of proton therapy would generally not be an accepted standard 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 proton beam therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve permanent authorization for trigger point injections.

You asked the Plan to pre-approve the requested services. You say that you are not receiving a timely appointment for urgent trigger point injections.The Plan denied your request. The Plan says there is no medical indication for more frequent trigger point injections at this time.

The Plan follows Medicare rules. Medicare rules say that trigger point injections are only covered under certain medical indications.

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 you have Elhors-Danlos syndrome, possible Fibromyalgia and depression. You have had trigger point injections in the past which have helped. You are on Lyrica, Tramadol, Diclofenac and Lidocaine Ointment for pain. Repeated Trigger point injections are not recommended for fibromyalgia. Rather,each episode needs to be evaluated prior to the administration of trigger point injections.  Therefore, the request is 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 the requested services have not been met.Therefore, we decided that the Plan does not have to pre-approve permanent authorization for trigger point injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 crowns (D2740), 2 prefabricated post and core in addition to a crown (D2954), and a root canal (D3310).
You asked the Plan to pre-approve the dental services. You say that the services were previously approved to be done at a different office. You say that for different circumstances, you needed to end the relation with the approved office. You say that the services are medically necessary. You also say that these services are needed as a result of an attack that was registered by the police. The Plan denied your request. The Plan says the requested dental services are not listed as covered.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve 6 crowns (D2740), 2 prefabricated post and core in addition to a crown (D2954), and a root canal (D3310).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the requested monitor. You say that the monitor is much better than pricking your finger three times a day.The Plan denied your request. The Plan says you are not using insulin three or more times a day.

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 does not indicate that you 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. Based on this information, we decided that Medicare rules for coverage of the requested monitor have not been met.Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Budesonide.
You asked the Plan to pre-approve a tier exception for Budesonide. You say that the exception is needed. The Plan denied your request. The Plan says Part B medications do not qualify for tier exceptions.
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a tier exception for Budesonide have not been met. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Budesonide.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance spectroscopy (CPT code 76390), for the enrollee.
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says research studies have found a lack of proof (evidence) that routine use of this study would improve the outcome for the enrollee's type of problem (condition).
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found at issue is whether magnetic resonance spectroscopy for the enrollee is a covered service under Medicare rules. The NCD indicates that the available evidence for Magnetic Resonance Spectroscopy (MRS) a diagnostic tool for distinguishing indeterminate brain lesions, and/or as an aid in conducting brain biopsies, remains inadequate to conclude that MRS is reasonable and necessary within the meaning of section 1862(a)(1)(A) of the Social Security Act, for use in the diagnosis of brain tumors. Therefore, CMS has reaffirmed its current national noncoverage determination for all indications of MRS. Our physician reviewer found the NCD indicates that magnetic resonance spectroscopy is a noncovered benefit for all indications. The requested service cannot be recommended. 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance spectroscopy (CPT code 76390), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 2.
You asked the Plan to pre-approve the dental service. You say that the enrollee needs the core build up for tooth # 2. The Plan denied your request. The Plan says core build up is not listed as a covered service.
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 core build up (D2950) for tooth # 2.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the coccygeal nerves.
You asked the Plan to pre-approve the coccygeal RFA. You say that it is felt that this procedure would provide longer lasting relief since she had an excellent response to the coccygeal nerve block. The Plan denied your request. The Plan says the requested procedure is not proven effective and is not reasonable and 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 the coccygeal RFA. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a female with severe, chronic, disabling coccyx pain. The enrollee has received several ganglion Impar blocks which provided 100% relief of her pain for several weeks. The physician trialed a sacrococcygeal nerve block on 1/14/21 which gave the enrollee 100% relief of her pain. The physician would like to do a radiofrequency ablation of the same nerves to ideally achieve significant long-term relief of the enrollee's pain. A case series and comprehensive, evidence-based review published in Pain Medicine in 2017 concluded that radiofrequency ablation of the sacrococcygeal nerves may serve as a useful treatment option for patients with coccydynia who have failed more conservative measures. Further research into this therapeutic approach and its benefit for coccydynia should incorporate a control group for comparison. At this time, it has not been demonstrated in the medical literature that radiofrequency ablation of the sacrococcygeal nerves is considered a medically reasonable and necessary treatment regimen for coccydynia. 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 coccygeal RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the coccygeal nerves.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.
You asked the Plan to pre-approve facet joint injections. You say that you do not want to increase the enrollee's medication dose, and the enrollee does not want surgery at this time. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee is experiencing radiculopathy from the shoulders to the fingers.
The Plan follows Medicare rules. Medicare rules state that facet joint injections are only covered when certain indications have been 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 joint injections. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested facet joint injections. Our physician reviewer found the enrollee has radicular pain symptoms and therefore this is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder arthroscopy (29823) provided on November 28, 2017.
You asked the Plan to pay for the shoulder arthroscopy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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 CPT Code Manual definition of code 29823 is arthroscopy, shoulder, surgical; debridement, extensive. We asked our coder 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 the shoulder arthroscopy. Our reviewer says that CPT code 29823 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include sufficient documentation to validate that an Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures was performed on November 28, 2017; therefore, this service cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the shoulder arthroscopy have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder arthroscopy (29823) provided on November 28, 2017.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT, lumbar spine; with contrast material (CPT code 72132).
You asked the Plan to pre-approve the CT scan. You say that your primary care physician (PCP) is ordering the CT scan, but your neurosurgeon said that he does not want you to have magnetic resonance imaging (MRI) done and that it must be a CT scan. The Plan denied your request. The Plan says they contacted your PCP and neurosurgeon who stated that the MRI that was approved would give them the information that they would need to evaluate you and develop a plan, and the CT scan was not necessary. The Plan states based on the providers ability to use the MRI results, the denial of the CT should remain unfavorable due to it not being reasonable or 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 the CT scan. Our physician reviewer found at issue is whether a CT scan of the lumbar spine with contrast for the enrollee is a covered service under Medicare rules. The NCD indicates that CT scans are covered if there is literature to support its use for the patient's condition and the scan is reasonable and necessary for the patient. Our physician reviewer found that the case file indicates that an MRI of the lumbar back has been approved and is the preferred test according to the primary care physician and the neurosurgeon. The provided records do not support the medical necessity or reasonableness of the requested service. The elements of the NCD are not satisfied. The requested service cannot be recommended. 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT, lumbar spine; with contrast material (CPT code 72132).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nuclear stress test.
You asked the Plan to pre-approve a nuclear stress test. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a nuclear stress test is covered for the indications established in the applicable LCD. 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 nuclear stress test. Our reviewer says that the requested nuclear stress test is not medically reasonable and necessary. Our physician reviewer found
that the enrollee was evaluated by his provider on March 1, 2021 for burning abdominal pain and an annual wellness visit. He denied chest pain, shortness of breath, palpitations, weakness or numbness. An electrocardiogram showed 1st degree AV block, RBBB, and no ST-T changes. There is no specific clinical rationale for the requested nuclear stress test. The requested imaging is not medically reasonable and necessary according to the coverage criteria established in the above LCD. 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 nuclear stress test have not been met. Therefore, we decided that the Plan does not have to pre-approve a nuclear stress test.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide continued coverage of a therapeutic continuous glucose
monitor.
You asked the Plan to provide continued coverage of a therapeutic continuous glucose monitor. You say that
the enrollee is unable to communicate or use a lancing device. The Plan denied your request. The Plan says
criteria for a CGM is not met.
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 the enrollee does not use insulin
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of
continued coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that
the Plan does not have to provide continued coverage of a therapeutic continuous glucose monitor.