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

We decided that the Plan does not have to pre-approve the Superion Vertiflex procedure for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says the available medical evidence is conflicting as to whether this procedure is safe and helpful. 
 
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is considered experimental, and more research is needed. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Superion Vertiflex procedure for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.
You asked the Plan to pre-approve a power wheelchair. The Plan denied your request. The Plan says that your medical records do not document a Doctor's Written Order, a home evaluation, the necessary 7 element order for a power wheelchair, the necessary evaluation that this is the appropriate device to meet your needs, and an evaluation of your ability to safely utilize this device.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 power wheelchair. Our reviewer says that a power wheelchair is not medically reasonable and necessary in this case. The provided medical records do not clearly state whether you have a personal mobility deficit that impairs participation in mobility related activities of daily living. The provided medical records do not clearly state whether your mobility deficit can be helped by the use of a walker, cane or manual wheelchair. The provided medical records do not clearly state whether you can safely operate a power mobility device. Our physician reviewer found that your condition does not meet Medicare criteria for a power wheelchair. 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 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (CPT Code 99292) provided August 18, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the medical records do not support this service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99292 is not supported in the medical record. Specifically, the medical records did not contain a critical care note of additional 30 minutes for date of service August 18, 2019. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (CPT Code 99292) provided August 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee meniscectomy/meniscal repair/meniscal transplant for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says the doctor's notes must show at six weeks of completed knee treatment before this is 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 surgery. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presents with a 10-year history of chronic left knee pain that had progressively worsened over 3 months. Pain increases with prolonged walking or standing. Clinical exam findings are generally consistent with the diagnosis of medial meniscus tear. X-rays show minimal degenerative changes. Under consideration is a request for left knee partial medial meniscectomy. Current evidence based medical literature supports meniscectomy for patients who have failed conservative treatment trial, unless mechanical symptoms such as locking predominate. In this case, there is no detailed evidence of mechanical symptoms, such as locking, that warrant immediate surgical treatment. There is no imaging evidence to support a traumatic tear and history would suggest a degenerative tear. Detailed evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol trial and failure has not been submitted. Therefore, this request for knee meniscectomy/meniscal repair/meniscal transplant is not medically necessary 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 the surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve knee meniscectomy/meniscal repair/meniscal transplant for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for partial foot, shoe insert with longitudinal arch, toe filler (CPT Code L5000) provided to the enrollee on August 8, 2019.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the medical records do not support this service.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The documentation submitted does not indicate that Partial foot, shoe insert with longitudinal arch, toe filler was dispensed at office. Therefore, the billed supply code cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. Therefore, we decided that the Plan does not have to pay for partial foot, shoe insert with longitudinal arch, toe filler (CPT Code L5000) provided to the enrollee on August 8, 2019.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for a refraction. We decided that the Plan does not have to waive the deductible for an office visit.
You asked the Plan to pay for a refraction. You say that this should be a covered eye exam. The Plan says that refractions are not covered by Medicare.
We decided that the Plan has to pay for a refraction.
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 an eye exam, which includes refraction, once a year. The file does not show that you have had a routine eye exam in the past 12 months. Therefore, we decided that the Plan has to pay for a refraction.
We also decided that the Plan does not have to waive the deductible for an office visit.
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 $160 deductible for all services besides emergency room visits, urgent care, anesthesia, and zero-cost preventative services. The item or service you asked the Plan to waive the deductible for is not an emergency room visit, urgent care, anesthesia, or a zero-cost preventative service. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $160 deductible for all other services. This cost sharing is a contractual obligation that had not been met at the time an office visit was received on September 9, 2019. Therefore, we decided that the Plan does not have to waive the deductible for an office visit.
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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve psychological testing for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are necessary prior to spinal cord stimulator implantation. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that psychological testing 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has lumbar and radicular pain at level 10 out of 10 that is exacerbated when sitting, standing, forward flexion, lifting, getting up from sitting, and walking. The records do not support that he meets the criteria for an evaluation of pain utilizing psychological testing, as his pain can be evaluated medically without psychological testing. We looked at this physician's review, the file, and Medicare rules. 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 psychological testing for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve anesthesia during a nerve block/injection procedure.
You asked the Plan to pre-approve the anesthesia. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show any of the indications for this.
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 anesthesia. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found according to the American Society of Anesthesiologists and the International Spine Intervention Society, minor pain management procedures require only local anesthesia under most routine circumstances including during SI joint injections. As such, the SI joint injection is not considered a typical primary procedure that warrants the use of deep sedation or monitored anesthesia care (MAC). Additionally, there were no clinical notes received from the provider that support the use of anesthesia services during this procedure for a medical reason (such as, a significant medical condition that would increase risk for complications without the use of sedation). The review has determined that the requested use of anesthesia services during a nerve block/injection is not medically reasonable and 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 anesthesia have not been met. Therefore, we decided that the Plan does not have to pre-approve anesthesia during a nerve block/injection procedure.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the x-ray provided on December 4, 2019. 
 
You asked the Plan to waive the deductible for the x-ray. You say that you had already met your deductible in April 2019. The Plan denied your request. The Plan says you have been charged 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 $750 deductible that applies towards basic imaging services.  
 
The x-ray you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards the x-ray. The record shows the retraction of the April 8, 2019 claim caused your deductible to be unsatisfied. 
 
This cost sharing is a contractual obligation that had not been met at the time the x-ray was received on December 4, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the x-ray provided on December 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing billed under code G0482.
You asked the Plan to pay for codes 80307 and G0482. You say that this claim should be paid. The Plan denied your request. The Plan says while code 80307 will be paid, the documentation criteria for code G0482 are not met. The Plan states the signature date of the Toxicology Profile is September 07, 2018; however, the billed date of service is November 13, 2019. Therefore, the billed date of service is not within the 1-year of the effective date of the toxicology profile. The Plan states multiple attempts were made to obtain additional information from the provider. Those requests were not responded to.
The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order and the medical records must be current and specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee on November 13, 2019 and billed under code G0482.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a breast procedure (CPT 19499) provided to the enrollee on July 18, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do 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 19499 is "unlisted procedure, breast." 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 the services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the medical records provided did not include a documented complete description of the unlisted code, therefore, the billed code cannot be verified. 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 Plan does not have to pay for a breast procedure (CPT 19499) provided to the enrollee on July 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic manipulative treatment.
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 that you do not meet criteria for coverage of chiropractic care as the medical records do not demonstrate that you have a subluxation of the spine.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Specifically, the record does not show subluxation of the spine by x-ray or physical exam. Therefore, we decided that the Plan does not have to pre-approve chiropractic manipulative treatment.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Aranesp.
You asked the Plan to pre-approve Aranesp. You say that alternative drugs were contraindicated or were previously tried with adverse outcome. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of Retacrit before it will cover Aranesp.
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 Aranesp. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Aranesp. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drug of Retacrit. The documentation does not support that Retacrit would likely be less effective and/or 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 Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Aranesp.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One for the enrollee. 
 
You asked the Plan to pre-approve Synvisc-One. The Plan denied your request. The Plan says that they did not receive documentation supporting the medical necessity for a step therapy exception. 
 
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 Synvisc-One. Our reviewer says that that Synvisc-One is not medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee has tried and failed. Monovisc and Orthovisc or that they would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Synvisc-One. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says this does not meet medical necessity criteria that requires a high level of physician supervision in combination with therapy services in an inpatient setting.
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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not require intensive physician or nursing supervision in an IRF. The enrollee may benefit from PT and OT but the documentation does not indicate that the enrollee requires this on an intensive level 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 Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tretinoin cream.
You asked the Plan to pre-approve self-administered drugs. You say that you are appealing The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B.
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 Tretinoin cream.
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.