Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One.

You asked the Plan to pre-approve Gel-One. You say that delaying the procedure will decrease the enrollee's ability to regain maximum function. The Plan denied your request. The Plan says you have not tried and failed Durolane, Gelsyn-3, and Synvisc/Synvisc-One.

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 Gel-One. Our physician reviewer found that you have a diagnosis of osteoarthritis of the knee. The Plan requires a trial of Durolane, Gelsyn-3, and Synvisc/Synvisc-One before they will approve the requested drug. In this case, you have not tried and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less effective or likely have adverse effects. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6545.

You asked the Plan to pre-approve the compression stockings. You say that the compression wraps are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met as there are no open wounds.

The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.

The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional trips. You say that exams need to be done before and after cataract surgery. The Plan denied your request. The Plan says your benefit only allows 60 trips for this service.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way trips per year.
We looked at your request, the records in the case file, and the rules. The file shows that 56 trips have been used this year. Once 60 trips have been used, you will have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the assistant surgeon services rendered on October 7, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided a clear denial reason for the services at issue. There is no documentation or explanation as to why the services cannot be paid per Medicare rules. Therefore, we decided that the Plan has to pay for the assistant surgeon services rendered on October 7, 2020.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system.
You asked the Plan to pre-approve the requested item. You say that you are a fall risk. The Plan denied your request. The Plan says the item is not a covered benefit.
The Plan must follow Medicare rules. The rules say that a power seat elevation feature is non-covered.
We looked at the file and the rules. The rules say that the requested item is not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the plastic surgery provided on September 19, 2019 by an out-of-network (OON) provider.
You asked the Plan to pay for the plastic surgery. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the plastic surgery provided on September 19, 2019 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic panel testing provided on October 15, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this panel testing must be billed with one procedural code.
The Plan must follow Medicare rules. Medicare rules say that genetic testing panels must be billed with a single procedure code.
We looked at the file and Medicare rules. This genetic testing panel was not billed with the appropriate coding. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic panel testing provided on October 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visits, surgery, and diagnostics to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the office visits, surgery, and diagnostics. You say that this enrollee has a rare neurologic condition and would like to see the sub-specialist in this condition due to rapid decline in function. The Plan denied your request. The Plan says the provider is out-of-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 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 the office visits, surgery, and diagnostics to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first 15 minutes of deep sedation/general anesthesia (D9222), subsequent 15 minute increments of deep sedation/general anesthesia (D9223), therapeutic parenteral drugs (D9612), and extractions (D7210) provided on February 3, 2021.
You asked the Plan to pay for the deep sedation/general anesthesia, therapeutic parenteral drugs, and extractions. You say that your insurance did not cover everything. The Plan denied your request. The Plan says the deep sedation/general anesthesia and therapeutic parenteral drugs are not covered benefits. The Plan also says that your benefit maximum of $1,000 has been exhausted.
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, first 15 minutes of deep sedation/general anesthesia (D9222), each subsequent 15 minute increment of deep sedation/general anesthesia (D9223), and therapeutic parenteral drugs (D9612) are not among those covered under this benefit. The Plan offers a $1,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit while processing this claim for the February 3, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the first 15 minutes of deep sedation/general anesthesia (D9222), subsequent 15 minute increments of deep sedation/general anesthesia (D9223), therapeutic parenteral drugs (D9612), and extractions (D7210) provided on February 3, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve the SNF care.. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or 
skilled therapy 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 the SNF care. have not been met. Specifically, medically necessary services can 
be obtained at a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, 
we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve the Intracept procedure. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says medical studies have not proven that the service or procedure is helpful for treatment of your health problem.
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 Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure remains experimental for the treatment of back pain. More research is needed to show safety and efficacy before this procedure will be covered. 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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) provided on April 6, 2021.
You asked the Plan to pay for the core buildup. You say that you believe this service should be covered. The Plan denied your request. The Plan says this service is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) provided on April 6, 2021.
Your complaint about your issues with the treating provider 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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested inpatient care is a medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for coverage for inpatient care have not been met because the requested level of care is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient treatment are met in this case. Our physician reviewer found that the record does show that at the time of inpatient admission the admitting physician would reasonably expect that the enrollee's necessary hospital care would span two midnights. There is a significant medical history of coronary artery disease, chronic kidney disease, hyperlipidemia, hypertension, and anemia. The enrollee is a current every-day smoker. Overall, there is a plausible increased risk for post-operative complications. Therefore, the requested acute inpatient hospital stay for approved procedure, shoulder arthroplasty (23472), is 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pre-approve acute inpatient hospital care.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgery for the Superion InterSpinous Spacer (Vertiflex) device.
You asked the Plan to pre-approve surgery for the Superion InterSpinous Spacer (Vertiflex) device. You say that the member has suffered with back pain for five (5) years, and this has greatly impacted the member's quality of life. You say that this procedure is a safer alternative to a spinal fusion. The Plan denied your request. The Plan says that the Medicare criteria for reasonable and necessary are not met as this device has not been shown to be safe and effective in long term studies and there is a lack of evidence to support that interspinous spacer devices are as safe and effective as the gold standard of decompression.
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 surgery for the Superion InterSpinous Spacer (Vertiflex) device. Our reviewer says that the requested Vertiflex device is not considered medically reasonable and necessary in this case. Our physician reviewer found that the Food and Drug Administration states that the Superion InterSpinous Spacer is indicated to treat skeletally mature patients suffering from pain, numbness, and/or cramping in the legs (neurogenic intermittent claudication) secondary to a diagnosis of moderate lumbar spinal stenosis, with or without Grade 1 spondylolisthesis, confirmed by imaging, evidence of thickened ligamentum flavum, narrowed lateral recess, and/or central canal narrowing. The Superion InterSpinous Spacer is indicated for those patients with impaired physical function who experience relief in flexion from symptoms of leg/buttock/groin pain, with or without back pain, who have undergone at least 6 months of non-operative treatment. The Superion InterSpinous Spacer may be implanted at one or two adjacent lumbar levels in patients in whom operative treatment is indicated at no more than two levels, from L1 to L5. In this case, the enrollee indicates that he has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The record indicates that imaging has demonstrated moderate to severe spinal stenosis at 43-L5, the level requested for treatment. The pain is exacerbated in flexion. The elements of the coverage criteria 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 surgery for the Superion InterSpinous Spacer (Vertiflex) device have not been met. Therefore, we decided that the Plan does not have to pre-approve surgery for the Superion InterSpinous Spacer (Vertiflex) device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transoral incisionless fundoplication procedure (43210, 43235).
You asked the Plan to pre-approve a transoral incisionless fundoplication. You say that the requested treatment is a medical necessity for you. The Plan denied your request. The Plan says rules for coverage for a transoral incisionless fundoplication have not been met because the requested procedure is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a transoral incisionless fundoplication is covered when the criteria in the Medicare rules section 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 a transoral incisionless fundoplication. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the record indicates that you have gastroesophageal reflux disease (GERD). The record submitted does not indicate that that symptoms are not completely responsive as judged by GERD Health Related Quality of Life (HRQL) scores measured on and off proton pump inhibition therapy. The elements of the coverage criteria are not satisfied. 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 transoral incisionless fundoplication have not been met. Therefore, we decided that the Plan does not have to pre-approve a transoral incisionless fundoplication procedure (43210, 43235).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the labial veneers (D2962) provided on April 27, 2021.
You asked the Plan to pay for the labial veneers (D2962). You say that the veneer on one tooth has deteriorated and will require extensive work if it is not repaired. You say that the work was completed to prevent additional damage and you are appealing the decision. The Plan denied your request. The Plan says veneers are excluded from coverage.
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 labial veneers (D2962) provided on April 27, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.

You asked the Plan to pre-approve the Vertiflex procedure. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says medical studies have not proven that the Vertiflex device is helpful for the enrollee's health problem.

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 procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 93-year-old man who is being treated for spinal stenosis, lumbar region, with neurogenic claudication. Current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression Vertiflex 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. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for the Vertiflex Superion interspinous device 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.