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

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the service is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an MRI of the lumbar spine. Our reviewer says that the service is not medically necessary. Our physician reviewer found clearly the enrollee has evidence of degenerative stenosis of her lumbar spine. However, there has been no clarification of the "escalation" of her symptoms since her prior MRI scan and she has not attempted a conservative course of therapy such as physical therapy (PT). While PT may not reduce her symptoms the criteria used for medical necessity requires a firm documentation of progressive symptoms, a red flag such as diminished reflex and/or a six week trial of PT with complete re-evaluation after completion. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the lumbar spine have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent.
You asked the Plan to pre-approve Dupixent. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Dupixent is not covered under the enrollee's Medicare Part B benefit.
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 Dupixent.
Benefits for Dupixent 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3000).
You asked the Plan to pre-approve foot orthotics. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3000).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar Vertiflex interspinous and/or interlaminar device (22869, 22870).
You asked the Plan to pre-approve a lumbar Vertiflex interspinous and/or interlaminar device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
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 a lumbar Vertiflex interspinous and/or interlaminar device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found FDA criteria have not been met to support the medical necessity of this procedure. You present with severe spinal stenosis at the L4/5 level which is not a supported indication for the Vertiflex procedure. Additionally, you are status post prior lumbar decompression at the L4/5 level which is an FDA contraindication for this procedure. Other contraindications have not been fully ruled out. Additionally, you are 81 years old and there is no evidence of a DEXA scan ruling out the presence of osteoporosis. Therefore, this request for the Vertiflex interspinous and/or interlaminar 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 a lumbar Vertiflex interspinous and/or interlaminar device have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar Vertiflex interspinous and/or interlaminar device (22869, 22870).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services from October 20, 2018 through June 3, 2019 provided to the enrollee.
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 enrollee does not have out-of-network benefits.
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. We cannot determine how the member was referred to this out-of-network provider. The health plan requires utilization of network providers when possible and available, and requires authorization for certain services. 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. 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 services from October 20, 2018 through June 3, 2019 provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approver the requested physician's services.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you
must receive care from in-network providers with the exception of emergency or urgent care, dialysis while
temporarily or if the care cannot be provided with an in-network provider, which requires prior authorization
from the plan.
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 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 the
requested physician's services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate for use in a spinal fusion surgery.
You asked the Plan to pre-approve the bone marrow aspirate. You say that this should be approved. The Plan denied your request. The Plan says all services aside from the unproven bone marrow aspirate use have been approved.
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 bone marrow aspirate. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation in the case file does not support that bone marrow aspiration for bone grafting is medically reasonable and necessary for the enrollee in this case. Bone marrow aspiration is not considered the standard of care for the treatment of the enrollee's condition. There is insufficient support for this procedure in the peer-reviewed medical literature. 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 bone marrow aspirate have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate for use in a spinal fusion surgery.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a panniculectomy (15830).
You asked the Plan to pre-approve a panniculectomy. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for this service.
The Plan follows Medicare rules. Medicare rules say that if the panniculectomy is being performed following significant weight loss, in addition to meeting the criteria noted above, there should be evidence that the individual has maintained a stable weight for at least six months.
We looked at the file and Medicare rules. The submitted records do not contain documentation that the enrollee's weight is stable and has been for at least six months. Based on this information, the rules for coverage of a panniculectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve a panniculectomy (15830).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says you do not have a
history of osteoporotic fracture, or previous treatment, contraindication, or intolerance to Zoledronic acid.
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 Prolia. Our physician reviewer found
that you have age-related osteoporosis without current pathological fracture. It is noted that you are on a
bisphosphonate break. The duration of treatment with a bisphosphonate is not documented, nor is the time of
the break. The Plan requires a history of osteoporotic fracture, or a trial of Zoledronic acid before they will
approve the requested drug. The documentation does not show that you have tried and failed the plan
requirements. The documentation is insufficient to demonstrate that Zoledronic acid would likely be less
effective, or would likely have adverse effects for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for home visits for hemodialysis (99512) provided from September 2, 2019 to September 30, 2019.
You asked the Plan to pay for home visits for hemodialysis. You say that these services should be paid. The Plan denied your request. The Plan says that services from providers who do not participate in Medicare are not covered.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. The documentation submitted in this file includes a signed agreement between the provider and an agent of the plan which approves coverage for home visits for hemodialysis billed with code 99512. The denial rationale attests that, although this was approved, it cannot be paid as the provider is not enrolled in Medicare. However, the services described by the code that was approved in advance by the plan are not Medicare-covered services and the plan was provided with the provider's NPI and tax identification number at the time of approval. Since the specific services from this specific provider were pre-approved, we find that the rules for payment of these services have been met. Therefore, we decided that the Plan has to pay for home visits for hemodialysis (99512) provided from September 2, 2019 to September 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter for the enrollee.
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the
enrollee is able to get around inside the home with a cane.
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 the requested device. Our physician
reviewer found that the enrollee is noted to have a personal mobility deficit, but the documentation does not
support that this deficit impairs participation in MRADLs. The documentation does not include a detailed gait
evaluation, neurologic exam of the motor/sensory system, or detailed musculoskeletal exam that would indicate
whether this mobility deficit can be helped by the use of a walker, cane or manual wheelchair. The enrollee is
noted to be ambulatory without restrictions on a July 10, 2019 progress note. Additionally, the enrollee's
diagnosis of meralgia paresthetica would cause pure sensory issues, and would not cause motor dysfunction in
the lower extremities. There is no evaluation of a trial of the enrollee on a PMD, or detailed neurologic and
upper/lower extremity musculoskeletal evaluation indicating that he is able to operate the PMD safely.
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 power scooter for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for presumed aspiration pneumonia following a recent stroke. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on September 25, 2019.
You asked the Plan to pay for the drug test. You say that the toxicology tests were ordered by the referring
physician in good faith, identifying the services to be medically necessary. The Plan denied your request. The
Plan says that the services provided were not urgent or emergent and could have been provided by a contracted
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 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 and the ordering provider in this case are not network providers with the Plan. The Plan
did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this
service. Therefore, we decided that the Plan does not have to pay for a drug test provided on September 25,
2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient therapy out of network for the enrollee.
You asked the Plan to pre-approve out of network providers. You say that the enrollee prefers the requested provider. The Plan denied your request. The Plan says there are network providers who can treat the enrollee.
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 outpatient therapy out of network for the enrollee.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after February 22, 2020.
You asked the Plan to pre-approve SNF care. You say that the requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says that the requested continuation of SNF care does not meet criteria.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal. We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before February 22, 2020. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after February 22, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Esophagogastroduodenoscopy (EGD) with Botox (43235 and J0585).
You asked the Plan to pre-approve Esophagogastroduodenoscopy (EGD) with Botox (43235 and J0585). You say that the requested EGD with Botox is medically necessary. The Plan denied your request. The Plan says the requested EGD with Botox 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 Esophagogastroduodenoscopy (EGD) with Botox (43235 and J0585). Our reviewer says that the requested EGD with Botox is not medically necessary. Our physician reviewer found the enrollee is with a diagnosis of a large esophageal hiatal hernia and a paraesophageal hernia. The enrollee has undergone robotic repair of a paraesophageal hernia with Nissen fundoplication, as well as balloon dilatation at the gastroesophageal junction. The enrollee has recurrent post-operative dysphagia. Benign-appearing moderate circumferential scarring or stenosis is documented. The enrollee does not have documentation of a medical condition for which EGD with Botox would be indicated. The requested EGD with Botox 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 Esophagogastroduodenoscopy (EGD) with Botox (43235 and J0585) have not been met. Therefore, we decided that the Plan does not have to pre-approve Esophagogastroduodenoscopy (EGD) with Botox (43235 and J0585).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 23, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require prior authorization.
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
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for laboratory services provided on September 23, 2019.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for Group Psychotherapy (90853) provided September 4, 2019 to September 30, 2019.
You asked the Plan to pay for the psychotherapy services. You say that the services were medically necessary and a covered service. The Plan denied your request. The Plan says that while they have agreed to approve the services, the claim cannot be processed until a corrected claim has been received.
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. While the plan states they will approve services if a corrected claim is submitted, the plan has failed to provide sufficient information detailing why a corrected claim is needed. The plan did not elaborate on a brief note about the type of bill. It's unclear why the claim is incorrect based on the information the plan provided. Therefore, we decided that the Plan has to pay for Group Psychotherapy (90853) provided September 4, 2019 to September 30, 2019.