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

We decided that the Plan does not have to pre-approve the Oxycontin 20mg ER tablet medication.
You asked the Plan to pre-approve this medication. You say that this medication is medically necessary for the enrollee. The Plan denied your request. The Plan says this medication is not a covered benefit under the enrollee's contractual policy.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Oxycontin 20mg ER tablet medication.
Benefits for this medication 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for osseous surgery (D4261) received on November 18, 2020.
You asked the Plan to pay an additional amount for osseous surgery. You say that you would like the Plan to pay more for this service. The Plan denied your request. The Plan says the correct amount was paid in this case.
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 out of network osseous surgery with a 50% coinsurance of the Plan allowed amount. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan does not have to pay an additional amount for osseous surgery. Specifically, the allowed amount of this service was $141.00. The record shows that the Plan paid 50% of this cost ($70.50). 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 pay an additional amount for osseous surgery (D4261) received on November 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve [complete description of item or service at issue, e.g. at issue is "a power wheelchair provided by The Wheelchair Store on January 12, 2016."]
You asked the Plan to pre-approve [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"]. You say that you would like reconsideration because without this feature, you cannot get food, access the refrigerator or a number of other activities. The Plan denied your request. The Plan says Medicare does not consider a power seat elevation fixture to be primarily medical in nature.
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 [complete description of item or service at issue, e.g. at issue is "a power wheelchair provided by The Wheelchair Store on January 12, 2016."]
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laminectomy/facetectomy and foraminotomy.
You asked the Plan to pre-approve surgical service. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this surgery is not clinically indicated.
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 surgical service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Magnetic Resonance Imaging (MRI) does not show significant neural compression. There is no documented spinal instability or fracture. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of surgical service have not been met. Therefore, we decided that the Plan does not have to pre-approve laminectomy/facetectomy and foraminotomy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on December 19, 2019, by
an OON provider.
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and
paid. The Plan denied your request. The Plan says prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for skilled nursing services provided on December 19,
2019, by an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cystoscopy provided on June 2, 2020.
You asked the Plan to waive the copayment for the cystoscopy. You say that you had similar services before
and never had to pay anything. You say that insurance should pay the full bill. The Plan denied your request.
The Plan says the copayment applied correctly.
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 $200
copayment for each visit to an outpatient hospital facility.
You have been asked to pay a $200 copayment for the cystoscopy. The cystoscopy falls within the "Outpatient
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 copayment for the cystoscopy provided on June 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve interspinous device.
You asked the Plan to pre-approve interspinous device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 interspinous device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has back pain. There is no instability on flexion and extension x-rays. The interspinous device remains experimental. More research is needed to show safety and efficacy of the device. Therefore, the enrollee does not meet criteria for the requested services. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve interspinous device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system and accessory tray.

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. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules say that a power seat elevation system is denied as non-covered. 

The requested items are a power seat elevation system and accessory tray. These items do not serve a purpose that is primarily medical in nature and are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system and accessory tray.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
You asked the Plan to pre-approve Vertiflex. You say that this treatment is considered safe and effective and is medically necessary for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex 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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show the safety and efficacy of Vertiflex. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Nexium 20mg capsule and the Alvesco 160mcg Inhalation Aerosol medications.
You asked the Plan to pre-approve these medications. You say that these medications are medically necessary for the enrollee. The Plan denied your request. The Plan says these medications are not a covered benefit under the enrollee's contractual policy.
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 the Nexium 20mg capsule and the Alvesco 160mcg Inhalation Aerosol medications.
Benefits for these medications 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. The requested Superion spacer is considered experimental in nature, as more research is needed to show safety and efficacy. The services are therefore not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed and bath chair.
You asked the Plan to pre-approve a total electric hospital bed and bath chair. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. Medicare rules also say that shower chairs are not covered because they are not primarily medical in nature. While a total electric hospital bed and a bath chair may be appropriate in this case, neither the Plan nor Medicare offers coverage for these items. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed and bath chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 2.
You asked the Plan to pre-approve the dental service. You say that tooth # 2 has recurrent decay present which extends distal, buccal, and lingual from the existing amalgam filling. You say that the decay is not below the crestal bone. You say that this tooth has a high risk of fracture due to the extent of decay and cracks. You also say that a full coverage crown is recommended. The Plan denied your request. The Plan says tooth # 2 has subcrestal caries present. The Plan also says that the crown for tooth # 2 is not medically necessary.
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 the dental service when the services are medically necessary and reasonable. 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 dental service. Our reviewer says that the crown is not medically necessary. Our physician reviewer found the provided documentation shows a deep defect on the distal aspect of the tooth to the level of the bone that would make it impossible to restore the tooth with a crown. As it not possible to properly place a crown in this instance where there is decay to the level of the bone, the reviewer found that a crown for tooth # 2 is not reasonable and there is no necessity for the requested crown. 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 the dental service have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 2.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a ForeseeHome monitoring system.
You asked the Plan to pre-approve the requested device. You say that the device indicates a move from dry to wet stages of macular degeneration. The Plan denied your request. The Plan says there are not enough medical studies showing the service is safe and effective in treating the enrollee's 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 requested device. Our physician reviewer found that in this case, the enrollee has scarred left exudative macular degeneration, and right mild dry macular degeneration. The standard of care in this situation is treatment with oral vitamins and monitoring with intermittent follow-up examinations. In the context of exudative macular degeneration that is being actively treated and closely monitored with examination and imaging, the requested device is not the standard of care for treatment or monitoring. There is no evidence that the ForeseeHome system improves disease outcomes, or that it would be superior for treatment of the enrollee's intermediate non-exudative macular degeneration as compared with standard treatments. Therefore, the home monitoring with ForeseeHome 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 the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a ForeseeHome monitoring system.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Injectafer 750mg/15ml injection.
You asked the Plan to pre-approve Injectafer. You say that Injectafer is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Injectafer. Our reviewer says that Injectafer is not medically necessary. Our physician reviewer found the enrollee's hemoglobin level is documented at 13.7 grams/dL as of March 3, 2021, with a mean corpuscular volume of 101 fL and an iron saturation of 16%. Her last ferritin level was 147 ng/mL. These values do not meet prior authorization criteria for use of Injectafer. These values do not meet the health plan's prior authorization criteria or criteria in the Medicare-approved major drug compendia for use of Injectafer. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have to pre-approve Injectafer 750mg/15ml injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower partial denture (D5214).

You asked the Plan to pre-approve a lower partial denture. You say that your provider told you that it was covered under your previous plan, but due to health concerns you submitted the request late. The Plan denied your request. The Plan says a lower partial denture is not covered under your 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, 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 a lower partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve office visits. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided to the enrollee by a network 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 Plan does not have to pre-approve office visits to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant 360 genetic testing provided to the enrollee on May 11, 2020.
You asked the Plan to pay for this testing. You say that this testing was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Guardant 360 genetic testing.
The Maximus Physician Reviewer determined that, in addition to likely providing prognostic information, the value of next generation sequencing (NGS) to predict candidates for specific mutation-driven treatment holds promise. The Plan argues that the technology associated with Guardant 360 is not recommended in expert guidelines for cancer types other than non-small cell lung cancer. The Plan states that there is no evidence that Guardant 360 is useful for breast cancer management, and that multigene panels are not recommended in NCCN Breast Cancer guidelines. The medical records show the enrollee is a 72-year-old woman with a diagnosis of widely metastatic breast cancer. Our Medical Director has concluded that the Plan is correct in this case. The documentation does not support that the Medicare coverage criteria for Guardant 360 genetic testing were met in this case. Breast cancer is not listed as a diagnosis that supports medical necessity.
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 testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant 360 genetic testing provided to the enrollee on May 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have lumbar spinal stenosis. The requested Superion spacer is considered experimental in nature, as more research is needed to show its safety and effectiveness. The services are therefore not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.