Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve kyphoplasty for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the records do not show a new (within 12 weeks) compression fracture.

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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee was being treated for age-related osteoporosis with current pathological fracture, vertebrae,
initial encounter for fracture. This enrollee notes persistent and ongoing low back pain with weakness in the
back of her legs. The pain is described as aching, deep, shooting, throbbing, discomforting, sharp and piercing
and occur persistently. Symptoms are aggravated by flexion, daily activity, changing positions, rolling over in
bed, standing, twisting, and walking. Exam reveals antalgic gait with use of walker. The pain is worsened in
back with forward flexion, extension, side bending and rotation. There is tenderness to palpation of the lumbar
paraspinal in the upper, midlevel, and lower bilaterally. She is noted to be kyphotic with severe discomfort.
MRI corroborates chronic compression fracture involving L4 with bony retropulsion, persistent edema
identified within the remaining L4 vertebral body as well as some enhancement, this suggests the presence of
instability of this fracture. There is evidence based medical peer-reviewed literature support for kyphoplasty as
a safe and effective procedure for patients with acute vertebral fractures (age less than 3 months). However,
documentation indicated there is not an established acute fracture or other inclusion factor. There is also
fracture retropulsion and evidence of spinal level instability on MRI, both exclusion factors. Therefore, the
requested Kyphoplasty L4 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve kyphoplasty for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional prosthesis accessories (L5828, L5845, L5848, L5850, L5856, L5964).

You asked the Plan to pre-approve the accessories. You say that The Plan denied your request. The Plan says this can be approved except for the K3 components.

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 accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation from the enrollee's treating medical practitioners do not support that the enrollee needs a microprocessor knee (C-leg). The request appears to exceed the enrollee's need as the documentation does not support that the enrollee will be exposed to unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis beyond the level of that which is afforded by L5704-L5707. The documentation does not reveal that the requested items are reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. 

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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional prosthesis accessories (L5828, L5845, L5848, L5850, L5856, L5964).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the spine.

You asked the Plan to pre-approve MRI. You say that you believe this is medically necessary. The Plan denied your request. The Plan says the denial of authorization for this MRI is correct.

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 MRI. Our reviewer says that you do not meet the Medicare criteria for the requested MRI. Our physician reviewer found you have severe radicular pain with failure of conservative treatment for at least 7 days. The record shows that there was another recent request for MRI which was already approved by the Plan but has not yet been completed. Therefore, this repeat request is not considered medically necessary at this time. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the spine.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Coolief radiofrequency ablation of the genicular nerve.

You asked the Plan to pre-approve the Coolief. You say that you would like reconsideration because the member's daily activities are limited due to pain. The Plan denied your request. The Plan says the member has not attempted other modalities to relieve their symptoms.

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 Coolief. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this service is considered experimental and is the subject of ongoing clinical trials. 

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 Coolief have not been met. Therefore, we decided that the Plan does not have to pre-approve the Coolief radiofrequency ablation of the genicular nerve.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation, removal of impacted tooth, first 15 minutes of deep sedation/general anesthesia, and each subsequent 15 minute increment of deep sedation/general anesthesia provided on October 19, 2020.

You asked the Plan to pay for the cone beam CT capture and interpretation, removal of impacted tooth, and deep sedation/general anesthesia services. You say that you would like to appeal these services. 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 cone beam CT capture and interpretation, removal of impacted tooth, first 15 minutes of deep sedation/general anesthesia, and each subsequent 15 minute increment of deep sedation/general anesthesia provided on October 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 14, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on October 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says needed care can be safely given in a lower level of care such as a skilled or subacute nursing care facility.

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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care. 

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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services you received from October 5, 2020, to December 11, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the services at issue are not manual manipulation of the spine. Acupuncture services are not covered when provided by a chiropractor. Therefore, we decided that the Plan does not have to pay for the acupuncture services you received from October 5, 2020, to December 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the
enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF
admission.

The Plan must follow Medicare rules. The rules say that an 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 reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that the complexity of the patient's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was
admitted for surgical repair of a hip fracture. He is being evaluated for the cause of a post-operative fever.
There are no complex nursing or rehabilitation needs.

The patient does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically
necessary care can be provided in a different level of care.

Additionally, there is not a reasonable expectation that this patient will be able to fully participate in and
benefit from the intensive rehabilitation therapy program provided in an IRF.

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 an 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 pulp vitality tests (D0460) provided on September 15, 2020.

You asked the Plan to pay for the pulp vitality tests. You say that the Plan does not specify what services are or are not covered. You also say that you would like this service to be covered. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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 pay for the pulp vitality tests (D0460) provided on September 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of residual tooth roots (D7250) provided on June
29, 2020.

You asked the Plan to pay for removal of residual tooth roots. You say that you were referred to the provider in
this case by your dentist. You say that you were not informed by the office that the provider did not accept
Medicare payments. You also say that the services should be covered. The Plan denied your request. The Plan
says removal of residual tooth roots is not a covered service even when provided by a participating provider.

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
removal of residual tooth roots (D7250) provided on June 29, 2020.
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 is with a history of lumbar spinal stenosis with neurogenic claudication. The requested spacer device remains experimental. More research is needed to show safety and efficacy of the device. Therefore, the requested Vertiflex device is not medically necessary at this time. 

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the rate of an amalgam filling for the resin-based composite (D2391) provided on September 17, 2020.

You asked the Plan to pay the rate of an amalgam filling for the dental services. You say that you have had the same dentist for 37 years. You say that the material used for a filling has never been an issue. You say that the dentist needs to be paid for the service that was performed. You also say that you feel that you should receive this alternate benefit. The Plan denied your request. The Plan says resin-based composite is not a covered service. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits.

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 resin-based composite is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the rate of an amalgam filling for the resin-based composite (D2391) provided on September 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the mandibular partial denture and sales tax provided on October 19, 2020.

You asked the Plan to pay for the mandibular partial denture and sales tax. You say that you were advised that you had 30% coverage. The Plan denied your request. The Plan says there is no coverage for dentures and the sales tax when services are not covered. The Plan also says that you did not contact them prior to the date of service to verify your benefits.

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 mandibular partial denture and sales tax provided on October 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hydroxyzine 50mg tablets.

You asked the Plan to pre-approve the hydroxyzine tablets. You say that you believe this medication is needed. The Plan denied your request. The Plan says this oral drug cannot be covered by Medicare Part B.

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 hydroxyzine 50mg tablets.

Benefits for the hydroxyzine tablets 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 prosthetic leg with an advanced knee/foot feature, and ankle rotation unit (L5981, L5986, L5828, L5845, L5858, L5850, L5848) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the request for a K3 knee and foot does not meet the Medicare criteria as reasonable and 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided ,there is no documentation that the enrollee meets the criteria for these items as she is currently walking with the use of an assistive device which is not consistent with being a K3 ambulator. 

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 a prosthetic leg with an advanced knee/foot feature, and ankle rotation unit (L5981, L5986, L5828, L5845, L5858, L5850, L5848) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral sacroiliac joint peripheral lateral branch radiofrequency lesioning at S1, S2, S3 levels.

You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied your request. The Plan says that the requested procedure is considered experimental, investigational or unproven for your condition and is not medically necessary 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. This is considered an experimental/investigative procedure because of the wide variation in efficacy reported in the peer reviewed literature. Our physician reviewer found that your condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral sacroiliac joint peripheral lateral branch radiofrequency lesioning at S1, S2, S3 levels.