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

We decided that the Plan does not have to pre-approve continued psychotherapy treatment to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the OON psychotherapy services. You say that you have been seeing this provider for years and feel that it is not right that continued care was denied without a transition period. You state this has exacerbated your condition due to additional anxiety and stress. The Plan denied your request. The Plan says you are receiving routine psychotherapy which can be provided by one of the Plan's qualified network providers. There is no medical reason that this cannot be furnished 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 items/services at issue in this appeal. Maximus requested records from the requested provider and did receive any to determine if active treatment is taking place. 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 continued psychotherapy treatment 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 pre-approve 8 additional extractions.
You asked the Plan to pre-approve the dental services. You say that the enrollee needs these services as a result of high dose chemotherapy. The Plan denied your request. The Plan says the additional extractions are not a covered benefit under Medicare or the medical plan guidelines. The Plan says that Medicare does not cover routine dental services. The Plan says that 2 extractions are covered per calendar year. The Plan also says that the frequency limit has been reached.
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 and extractions are listed as covered, the frequency limit has been reached. The record shows that the Plan previously approved 2 of the requested extractions. Therefore, we decided that the Plan does not have to pre-approve 8 additional extractions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve high frequency chest wall oscillation device (HFCWOD) (E0483).
You asked the Plan to pre-approve HFCWOD. You say that CMS announced a temporary suspension of enforcement of certain clinical coverage criteria that applies to respiratory devices, allowing clinicians maximum flexibility to determine clinical need for such devices. The Plan denied your request. The Plan says the clinical documentation submitted shows that the enrollee does not have a covered diagnosis and does not meet the Medicare criteria.
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are covered only for patients with cystic fibrosis, bronchietasis, or certain neuromuscular diseases. The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve high frequency chest wall oscillation device (HFCWOD) (E0483).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740), core build up (D2950), a partial upper denture (D5213), and a partial lower denture (D5214).
You asked the Plan to pre-approve the dental services. You say that these services should be covered. The Plan denied your request. The Plan says crowns and other restorative services are covered once every 5 years. The Plan says that partial dentures are covered once every 5 years. The Plan also says that these frequency limits have been reached.
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 and the services are listed as covered, the frequency limits have been reached. The record shows that the Plan paid for a crown and core build up that you received for tooth # 6 that you received on June 18, 2018. The record shows that the Plan paid for partial dentures that you received on July 30, 2018. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740), core build up (D2950), a partial upper denture (D5213), and a partial lower denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the requested device. You say that the enrollee's fingers are sore. The Plan denied your request. The Plan says a continuous glucose monitor is not covered in the enrollee's medical circumstance.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation does not indicate that the enrollee uses insulin with at least three daily injections, and requires frequent self-adjustment of insulin dosage based on the blood glucose testing results. 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 continuous glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial knee replacement.
You asked the Plan to pre-approve the requested services. You say that you want a partial replacement due to a bad experience with a mastectomy. 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 the requested services. Our physician reviewer found that the imaging studies show too much degenerative joint disease (DJD) of the knee for a partial knee replacement to be successful. There is severe DJD patella femoral and lateral compartment severe. Therefore, a partial knee replacement is not appropriate 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a partial knee replacement.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Monovisc.

You asked the Plan to pre-approve Monovisc. You say that you would like reconsideration because this drug should be covered by your insurance. The Plan denied your request. The Plan says in order for this request to be eligible for coverage under your medical benefit, your medication must be supplied by your medical provider or facility.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Monovisc. 

Benefits for Monovisc 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 a pneumatic compression device (E0652).
You asked the Plan to pre-approve a pneumatic compression device. You say that the enrollee requires this device in contract to a pump which would not be effective for her condition. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the enrollee has not completed a 4 week trial using a basic pump (E0650 or E0651).
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vision services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve vision services. You say that you would like approval for these services to be provided out-of-network. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 vision services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the knee walker (E0118).

You asked the Plan to pre-approve the knee walker. You say that you would like reconsideration because you are non-weight bearing and would have to hop everywhere when using a standard crutch, walker or cane. The Plan denied your request. The Plan says the requested equipment does not meet medical necessity criteria for your condition.

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, we decided that Medicare rules for coverage of the knee walker have not been met. Specifically, this equipment is not a covered benefit because there is insufficient published clinical literature demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for these products. Therefore, we decided that the Plan does not have to pre-approve the knee walker (E0118).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the FreeStyle Libre Continuous Glucose Monitor.
You asked the Plan to pre-approve the FreeStyle Libre Continuous Glucose Monitor. You say that you would like reconsideration because you disagree with the denial of the continuous glucose monitor. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria based on lack of documentation of blood sugar checks greater than 4 times per day, 3 or more daily insulin injections or frequent insulin adjustments by the enrollee.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the FreeStyle Libre Continuous Glucose Monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve the FreeStyle Libre Continuous Glucose Monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the inpatient hospital care provided on September 8, 2020, September 10, 2020 and September 26, 2020.
You asked the Plan to waive the coinsurance for the inpatient hospital care. You say that you received a bill for copayments due. The Plan denied your request. The Plan says the coinsurance 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 15% coinsurance for each in-network, Medicare- covered hospital stay. You have been asked to pay a total of $44.14 for the inpatient hospital care.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
September 8, 2020
Inpatient Hospital Care
$112.11
15%
$16.82
September 10, 2020
Inpatient Hospital Care
$77.78
15%
$11.67
September 26, 2020
Inpatient Hospital Care
$112.11
15%
$15.65-less than standard 15%
TOTAL:
$44.14
The inpatient hospital care falls within the "Inpatient Hospital Care" 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 coinsurance for the inpatient hospital care provided on September 8, 2020, September 10, 2020 and September 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation and three extractions to be provided by an oral surgeon.
You asked the Plan to pre-approve the comprehensive oral evaluation and extractions. You say that you need these services to be approved for coverage. The Plan denied your request. The Plan says dental services are only covered when they are performed by a participating general dentist. The Plan also says that dental services performed by an oral surgeon 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 pre-approve a comprehensive oral evaluation and three extractions to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a provisional crowns (D2799), guided tissue regenerations (D4266), surgical placements of implant body: endosteal implants (D6010), custom fabricated abutments (D6057), abutment supported porcelain fused to metal crowns (D6059), and bone grafts at time of implant placement (D6104) for tooth #'s 5 and 6.
You asked the Plan to pre-approve the provisional crowns, guided tissue regenerations, endosteal implants, custom fabricated abutments, abutment supported crowns, and bone grafts. You say that you would like to appeal these services. The Plan denied your request. The Plan says these services are not covered under your benefit plan.
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 provisional crowns (D2799), guided tissue regenerations (D4266), surgical placements of implant body: endosteal implants (D6010), custom fabricated abutments (D6057), abutment supported porcelain fused to metal crowns (D6059), and bone grafts at time of implant placement (D6104) for tooth #'s 5 and 6.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular panel testing provided on December 10, 2020.
You asked the Plan to pay for the testing services. You say that the documentation prove medical necessity. The Plan denied your request. The Plan says the screening testing is not a benefit for the diagnoses listed on the claim.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The file shows the enrollee received urinary tract infection (UTI) molecular testing. In this case, there are insufficient medical records showing the results of the testing will be used as part of a specific treatment strategy. The testing services were requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the molecular panel testing provided on December 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and four additional intraoral periapical x-rays provided on February 15, 2021.

You asked the Plan to pay for the intraoral periapical x-rays. You say that you would like these x-rays to be covered. The Plan denied your request. The Plan says these services 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 first intraoral periapical x-ray and four additional intraoral periapical x-rays provided on February 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device 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 a Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee was being treated for spinal stenosis with neurogenic claudication. She presented with low back, and bilateral sacroiliac region pain. There is no radiation. The pain is constant and described as sharp, aching (pulling pain), burning and stabbing. Associated symptoms include difficulty walking and difficulty sleeping. There is continued back pain with neurogenic claudication. Exam revealed the reflexes are 1+ in the bilateral ankles. There is paresthesia noted at right L5 and left L5. There is paraspinous and facet tenderness, SI joint tenderness and PSIS tenderness. Straight leg raise is negative. However, current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device 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 as discussed above. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of "moderate" spinal stenosis (including the planned levels of implantation, L3-4 and L4-5.) FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. Detailed documentation is not evident regarding discussion of spinal instability on flexion/extension films or scoliosis of the lumbar spine with no documentation of the Cobb angle. There is no discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in this enrollee. 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 Vertiflex device at L3-4 and L4-5 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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study to be provided by an out-of-network provider.
You asked the Plan to pre-approve the sleep study. 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 a sleep study to be provided by an out-of-network provider.