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

We decided that the Plan does not have to pre-approve Carboplatin, Pemetrexed, and Pembrolizumab.
You asked the Plan to pre-approve Carboplatin, Pemetrexed, and Pembrolizumab. You say that this drug
regime is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the
coverage criteria have not been met.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Carboplatin, Pemetrexed, and
Pembrolizumab. Our reviewer says that the requested drugs are not medically reasonable and necessary. Our
physician reviewer found the enrollee has been diagnosed with stage III non-small cell lung cancer. In this
case, the enrollee has already tried a PD-1 inhibitor drug, Imfinzi. Therefore, a drug regimen containing
Pembrolizumab cannot be approved.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Carboplatin, Pemetrexed, and Pembrolizumab have not been met. Therefore, we
decided that the Plan does not have to pre-approve Carboplatin, Pemetrexed, and Pembrolizumab.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes (CPT code 97530 x4), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says notes must show proof of skill care was needed to address the enrollee's problem and help restore their function. The Plan states the notes show no reason why the enrollee has had limited changes in their function since care started. The Plan states the notes do not show that the skills of a therapist are needed. The Plan states a home program is appropriate at this time.
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 physician reviewer found based on the medical records provided there is no documentation that the requested therapy is generally accepted as specific and effective therapy for the enrollee's condition. Based on the available records the patient appears to have made minimal if any improvement with twelve therapy sessions. The enrollee is still reporting 10/10 knee pain and poor lumbar flexion and extension. Further skilled therapy at this point does not appear to be likely to achieve any significant improvement in the enrollee's symptoms or functional status. Further utilization of the home exercise program and/or follow-up with her medical provider for re-evaluation of the enrollee's condition appears appropriate at this point. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 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 pre-approve therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes (CPT code 97530 x4), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on March 4, 2021.
You asked the Plan to pay for a limited oral evaluation. You say that the service should be covered. The Plan denied your request. The Plan says the service at issue is not a covered 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 pay for a limited oral evaluation (D0140) provided on March 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the structural allograft services coded 20931 provided on
November 9, 2020.

You asked the Plan to pay for the structural allograft services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the
documentation.

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 20931 is allograft, structural, for spine surgery only (List
separately in addition to code for primary procedure).

We find that CPT code 20931 is not supported in the medical record. Specifically, the operative report did not include documentation of a structural allograft, for spine surgery only (listed separately in addition to code for primary procedure); therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the structural allograft services have not been met. Therefore, we decided that the Plan does not have to pay for the structural allograft services coded 20931 provided on November 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fluid flow injection services.

You asked the Plan to pre-approve the fluid flow injection services. You say that the enrollee has tried several
alternative treatments to relieve the pain, with little to no improvement. You say that the enrollee is a candidate
for knee surgery but would like to avoid that if possible. You say that the clinical notes provided support the
need for the requested services. The Plan denied your request. The Plan says the requested services are
considered experimental and investigational, as it is not identified as widely used and generally accepted for the
proposed use.

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 fluid flow injection services. Our
reviewer says that fluid flow injection services are not considered medically reasonable and necessary in this
case. Our physician reviewer found as chronic pain in his elbow, knees and ankles. He is taking Methadone and
oxycodone for pain. Fluid flow injections are an experimental/ investigational procedure.

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 fluid flow injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve fluid flow injection services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on March 3, 2021.
You asked the Plan to pay for periodontal maintenance. You say that the services should be covered. The Plan denied your request. The Plan says the benefit maximum had already been met.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of periodontal maintenance have not been met. Specifically, the record shows that you had exhausted your dental benefit maximum prior to this date of service. Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on March 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not need an intensive rehab program with a team of specialized professionals.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that you were admitted to the acute care hospital for repair of a torn medial meniscus of knee and were discharged home. Your medical conditions are stable. There are no complex nursing needs. You do not require treatment by multiple therapies in an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program.
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) provided on November 16, 2020.
You asked the Plan to pay for the dental services. You say that you were told by a plan representative that you had dental coverage. The Plan denied your request. The Plan says your dental coverage includes preventive dental services only. The Plan says the services that you received are not preventive dental services. The Plan also says that the services you received 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 limited oral evaluation (D0140), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) provided on November 16, 2020.
Your complaint about being misinformed by a plan representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that the services are necessary. The Plan denied your request. The Plan says the services are 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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 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 the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection procedure for sacroiliac (SI) joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed (CPT code 27096), for the enrollee.
You asked the Plan to pre-approve the injection. You say that the services are necessary. The Plan denied your request. The Plan says the Medicare rules have not 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 the injection. Our physician reviewer found the criteria for injection not met. There is no documentation of physical exam findings localizing the pain to the SI joint. More info 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve injection procedure for sacroiliac (SI) joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed (CPT code 27096), for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on February 17, 2020.
You asked the Plan to pay for the ambulance services. You say that you did not request this service. The Plan
denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on February 17, 2020. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on February 17,
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a fitness tracker, shoes and a heart rate monitor purchased on December 16, 2020 under the Wellness Allowance.

You asked the Plan to reimburse you for the fitness tracker, shoes and a heart rate monitor. You say that you should be reimbursement because of Covid-19 as this is the equipment you use for fitness. The Plan denied your request. The Plan says these items are not covered under the Wellness Allowance and not covered under the expanded benefit in place at the time, which covered exercise equipment that you can use at home.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a Wellness Allowance benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

The Plan's rules for coverage of these items has not been met. Therefore, we decided that the Plan does not have to reimburse you for a fitness tracker, shoes and a heart rate monitor purchased on December 16, 2020 under the Wellness Allowance.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided from February 5, 2020, to December 22, 2020.
You asked the Plan to pay for the dental services. You say that the dental services that you received in 2020 should all be covered. The Plan denied your request. The Plan says up to $400 will be reimbursed for dental services each year. The Plan says that this benefit has been exhausted. The Plan also says that the claim for February 5, 2020 was reprocessed and $400 was reimbursed for dental services that were performed.
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 maximum benefit has been exhausted for 2020 with the reprocessing of the claim for February 5, 2020. Therefore, we decided that the Plan does not have to pay for the dental services provided from February 5, 2020, to December 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on February 17, 2021.

You asked the Plan to pay for a comprehensive oral evaluation. You say that you were not aware that the service would not be covered. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every 3 Plan years.

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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been met.

Specifically, the record shows that you had exceeded the frequency limit prior to this service on June 15, 2020. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on February 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (CPT
code 22869 and 22870), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that the enrollee has failed conservative treatment,
physical therapy, medications, injections, and various non-sustainable treatments. The Plan denied your
request. The Plan says there does not appear to be a contraindication to the gold standard therapy (a
laminectomy) in this case and the evidence for the procedure does not appear to be widely adopted as the
standard of care at this time.
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 items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the
device.
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 the Vertiflex Superion device placement surgery (CPT code 22869 and 22870), for the
enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) received July 29, 2020.
You asked the Plan to pay for the periodontal maintenance. You say that this has always been covered by previous insurance. The Plan denied your request. The Plan says the requested service is not covered under your supplemental 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 pay for the periodontal maintenance (D4910) received July 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services are available in-network.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve services to be provided by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 2, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all
hospice care from the effective date of election to the date of discharge or revocation. During the election, feefor-
service Medicare also covers attending physician services and all care unrelated to the terminal illness until
the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for physician's services provided on December 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Lite Test Strips, for the enrollee.
You asked the Plan to pre-approve the strips. You say that the strips are necessary. The Plan denied your request. The Plan says the enrollee is required to try and fail the covered alternatives before we can cover the requested product or the enrollee's doctor needs to provide a clinical reason for why the enrollee cannot use the covered alternatives. The Plan states their records do not indicate that the enrollee has tried and failed the covered alternatives. The Plan states the enrollee's doctor did not provide documentation indicating the enrollee has tried and failed the covered alternatives or a clinical reason for why the enrollee is unable to use the covered alternatives.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, there were no records provided to verify the information submitted does not indicate that the enrollee has tried and failed formulary alternatives. Therefore, we decided that the Plan does not have to pre-approve Freestyle Lite Test Strips, for the enrollee.